Bilateral obturator hernia diagnosed by computed tomography: a case report with review of the literature

Unusual causes of Small bowel obstruction: a review of the literature and revisited cross-sectional imaging checklist

Intestinal obstruction is a common surgical emergency with high morbidity and mortality. Patients presenting with features of small bowel obstruction need urgent evaluation to avoid complications such as bowel gangrene, perforation, or peritonitis. Imaging is necessary in most cases of suspected bowel obstruction, to take an appropriate decision, for apt patient management. Among the common causes of small bowel obstruction, adhesions, external herniae, malignancies, and Crohn's disease top the chart. Imaging helps in determining the presence of obstruction, the severity of obstruction, transition point, cause of obstruction, and associated complications such as strangulation, bowel gangrene, and peritonitis. This review is based on the cases with unusual causes of bowel obstruction encountered during our routine practice and also on the extensive literature search through the standard textbooks and electronic databases. Through this review we want our readers to have sound knowledge of the imaging characteristics of the uncommon yet important causes of bowel obstruction. We have also revisited and structured a checklist to simplify the approach while reporting a suspected case of small bowel obstruction. Imaging plays a key role in the diagnosis of small bowel obstruction and in determining the cause and associated complications. Apart from the common causes of small bowel obstruction, we should also be aware of the uncommon causes of small bowel obstruction and their imaging characteristics to make an accurate diagnosis and for apt patient management.

Robotic transabdominal preperitoneal repair for bilateral obturator hernia: a video vignette

Obturator hernias (OHs) are a rare cause of bowel obstruction that requires immediate surgical intervention to prevent morbidity and mortality. Patients with OHs present with acute intestinal obstruction secondary to incarceration, with a high morbidity and mortality rate due to delayed diagnosis and treatment. Although several surgical approaches have been reported, a standard approach for OH treatment has not yet been established. Here, we report the case of a 74-year-old woman who presented with bilateral OHs. The patient presented at our institution with pain in the left lower quadrant. Computed tomography revealed preperitoneal fat in both obturator foramen. Robotic transabdominal preperitoneal (R-TAPP) bilateral OH repair was performed, and a mesh was placed over both obturator foramen. The patient recovered without postoperative complications and was discharged on postoperative day 2. This suggests that the R-TAPP approach is safe for OH repair without incarceration.

Obturator hernia (the little old lady's hernia) diagnosed via computed tomography: a case report

Obturator hernia is an infrequent clinical entity of abdominal wall hernia, accounting for an incidence rate ranging from 0.073 to 2.2% of all hernias and being responsible for 0.2-1.6% of all cases of mechanical intestinal obstruction. The computed tomography (CT) scan, as an imaging modality, is critical in improving the diagnostic rate of obturator hernia.

Case presentation

The authors herein report an 87-year-old thin male patient with a known history of chronic obstructive pulmonary disease who presenting with complaints of abdominal pain for 3 days and constipation for 2 days, as well as one episode of vomiting without any features of peritoneal irritation, which was diagnosed early as a right-sided obturator hernia via CT and managed with exploratory laparotomy with hernia reduction and polypropylene mesh repair.

Discussion

Obturator hernia is a rare surgical phenomenon with a varied clinical spectrum, ranging from asymptomatic to presenting as intestinal obstruction. The CT scan plays a critical role in the detection of obturator hernias, which ameliorates the possible significant postoperative morbidity and mortality.

Conclusion

This report demonstrates that a high index of suspicion combined with CT imaging aids in early diagnosis and management, thus overcoming the reluctant morbidity.

Two cases of obturator hernia in patients undergoing hemodialysis: case report and literature review

Background

Obturator hernia (OH) is an extremely rare abdominal wall hernia with risk factors including aging, female sex, emaciation, and increased abdominal pressure. Its symptoms are nonspecific, and diagnosis is often delayed; however, this delay can lead to a fatal course. Therefore, early diagnosis and surgical intervention are necessary to reduce the mortality rate associated with OH. Considering the risk factors for OH, patients currently undergoing hemodialysis (HD) may be particularly vulnerable to OH. Here, we report two cases of OH in patients undergoing HD along with a review of the relevant literature.

Case presentation

Case 1 included a 76-year-old female undergoing HD due to autosomal dominant polycystic kidney disease. She was hospitalized for upper abdominal pain, vomiting, and diarrhea. On the day of hospitalization, she was diagnosed with OH using computed tomography and underwent emergency surgery. Case 2 included a 90-year-old emaciated female who was admitted to our hospital for projectile vomiting while undergoing HD. She was diagnosed with OH and shock, but surgery was not performed due to shock. Nonetheless, her blood pressure gradually increased, and she completely recovered. Spontaneous reduction in OH was confirmed on the third day of hospitalization. Both patients recovered well.

Conclusions

The symptoms of OH are non-specific, and certain symptoms such as vomiting and anorexia are often overlooked because they are common in patients undergoing HD. It is important to include OH in the differential diagnosis of digestive organ symptoms in patients undergoing HD, especially in those with risk factors for OH, such as elderly female patients on HD due to autosomal dominant polycystic kidney disease.

An unusual case of early-stage obturator hernia causing bowel obstruction and strangulation

Obturator hernia is rare, contributing to less than 2% of the total incidence of small bowel obstructions. The diagnosis of obturator hernia is still a big challenge today. Abdominopelvic Computed Tomography scans have better diagnostic value preoperatively, showing the bowel loop between the pectineus and obturator externus muscle. We report an unusual case of a 77-year-old woman who presented to the emergency ward with an acute abdominal pain. Plain abdominal radiography showed small bowel obstruction. However, a computed tomography scan only showed signs of closed-loop obstruction and strangulation with bulging of the peritoneum through the obturator foramen. Exploration by laparotomy allowed complete evaluation of the obturator canal and confirmed the diagnosis of obturator hernia as a cause of bowel obstruction and strangulation.

Obturator hernias: a systematic review of the literature

PURPOSE

Obturator hernias (OH) are extremely rare hernias, accounting for 0.07-1% of all hernias. This is the first systematic review investigating their presentation, imaging, treatment outcomes, and recurrence rate.

METHODS

After a detailed search in electronic search engines, 74 studies matched our criteria. A review of these reports was conducted and the full texts were examined.

RESULTS

A total of 146 patients with a mean age of 78.8 years were included in our analysis, with 40.1%, 29.9%, and 25.2% of patients suffering from either a right, a left or bilateral OH, respectively. OH were associated with non-specific symptoms and signs; bowel obstruction being the most common. Howship-Romberg sign was present in 56.2% of patients. Computed tomography (CT) scan was the most frequently used diagnostic modality, inversely associated with perioperative mortality. Mesh repair demonstrated a significantly improved perioperative morbidity rate, compared with non-mesh repair. Approximately 30% of patients underwent a laparoscopic operation, which was associated with significantly decreased morbidity and mortality rate as well as length of hospital stay, compared with the open repair.

CONCLUSION

OHs are not associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair.

An Unusual Case of Obturator Hernia Detected in an Elderly Man by Computed Tomography

Obturator hernia is a rare condition, characterized by the herniation of an intestinal segment between the obturator and the pectineus muscles through the obturator foramen. Obturator hernias usually occur in the elderly and are less common in males than in females, with a male-to-female ratio of about 1/14. In recent years, the use of diagnostic imaging, especially CT, to determine the causes of intestinal obstruction has been improved to allow for an early and accurate diagnosis, even of obturator hernias, which are extremely rare in male patients. We report a thin elderly man, without a history of surgery and with chronic constipation and an unremarkable Howship-Romberg sign, which was correctly diagnosed before surgery as an obturator hernia using CT.

Which Patients Are a Better Candidate of Laparoscopic Repair in Obturator Hernia Patients?

PURPOSE

Obturator hernia is a difficult disease to diagnose. If a surgical treatment is delayed in obturator hernia, a bowel resection may be required due to strangulation. The surgical treatment of this disease is to use a classical laparotomy. Recently, the laparoscopic approach has been reported and reviewed for efficiency. We checked the indicators that determine the most appropriate surgical method according to the patient's condition.

METHODS

In the study, a single-institution, retrospective analysis of surgical patients undergoing an obturator hernia surgery between 2003 and 2018 was performed. The patients were divided into a laparoscopic group (5 patients underwent laparoscopic repair; no intestinal resection) and an open group (13 patients who underwent open repair; 10 with and 3 without intestinal resection). The outcomes were compared between the groups. We analyzed the relevant factors that could predict the proper method of surgery.

RESULTS

A total 18 patients were included in the study. All patients were female, with body mass index (BMI) of under 21 kg/m². Of the various factors, only the WBC and CRP counts were the factors that had shown significant differences between the two groups. It is noted that patients with open surgery had a higher WBC counts (10406 versus 6520/μl; p=0.011) and CRP counts (7.84 vs. 0.32 mg/dl; p=0.027).

CONCLUSION

Obturator hernia can be treated with a laparoscopic surgery. The choice of surgical treatment can be considered in advance through the review of the patient's WBC count or CRP count.

Emergency incarcerated obturator hernia repair with biologic mesh in a male patient after ipsilateral hip disarticulation: A case report

INTRODUCTION

An obturator hernia is an uncommon form of abdominal hernia that is difficult to diagnose due to its non-distinct presentation. This case investigates an emergency treatment of an obturator hernia presenting in a patient with an ipsilateral hip disarticulation in a 266-bed community hospital.

PRESENTATION OF CASE

A 53-year old man with a history of a left hip disarticulation 3-weeks prior presented to the emergency department with fever, nausea, vomiting, and diarrhea for the past 5-days. An elevated WBC and presence of gas within the hip stump on CT led to an emergency operation to rule out necrotizing fasciitis within the stump. Opening of the stump incision revealed two herniated loops of small bowel corresponding to the left obturator foramen, revealing the diagnosis of an incarcerated obturator hernia. The bowel was reduced and secured within the hip stump and the defect was covered with Strattice biologic mesh.

DISCUSSION

Obturator hernias are rare and can involve vague symptoms, but it is essential to make an accurate diagnosis and repair the defect on an emergency basis. Obturator hernias may appear in the setting of a hip disarticulation, being caused by iatrogenic anatomic alteration, and can be treated in a community acute care hospital.

CONCLUSION

Being aware of the possibility of obturator foramen herniation and bowel incarceration as part of the differential diagnosis for patients with abdominal pain after a prior hip disarticulation can facilitate prompt diagnosis and reduce morbidity and mortality.

The feasibility of laparoscopic management of incarcerated obturator hernia

BACKGROUND

Obturator hernia (OH), a rare cause of acute small bowel obstruction, requires immediate surgical intervention to prevent serious complications and mortality. We assessed the safety and efficacy of laparoscopic surgery in patients with incarcerated OH presenting with acute abdomen in an emergency setting.

METHODS

Data pertaining to patients diagnosed with incarcerated OH between 2011 and April 2015 at our hospital were reviewed. Patients' characteristics, operation details and postoperative outcomes were retrospectively analyzed.

RESULTS

All ten patients diagnosed with incarcerated obturator hernia during the reference period were females (average age 72.1 ± 11.8 years; average weight 44.1 ± 6.9 kg; average body mass index 17.8 ± 2.1 kg/m²; average operating time 63 ± 15 min; average hospital stay 6.2 ± 6.6 days). Twelve occult hernias, including six contralateral OHs, two ipsilateral femoral hernias and two bilateral femoral hernias were detected in six patients (60 %), which were simultaneously repaired after laparoscopic exploration. Nine patients (90 %) were successfully treated with synthetic mesh by laparoscopic technique. Only one case required intraoperative conversion to open surgery due to strangulated intestine with perforation. Wound infection was reported in one patient who had undergone bowel resection, but with an eventual complete recovery. Postoperative period was uneventful in the other nine patients. No recurrence or complications were reported on follow-up (mean duration of follow-up: 6-54 months).

CONCLUSION

In this study, laparoscopic technique was associated with a reduced duration of hospital stay and fewer complications. In addition to being a safe and minimally invasive strategy, it allowed for simultaneous diagnosis and treatment of occult hernias during the same procedure. The approach may be a better option for the treatment of incarcerated OH and occult hernias in selected patients.

Laparoscopic total extraperitoneal repair of preoperatively diagnosed bilateral obturator and incidental bilateral femoral herniae

Obturator hernia (OH), a rare type of hernia, is associated with high morbidity and mortality. Diagnosis is often delayed as clinical symptoms are typically non-specific. OH is frequently associated with other occult inguinopelvic herniae. Early diagnosis is vital to decrease morbidity and mortality. We report the case of a 75-year-old woman who presented to the surgical outpatients' department with non-specific bilateral groin pain radiating to the thighs. CT of the pelvis demonstrated bilateral OH with no radiological evidence of bowel obstruction. Semiurgent elective laparoscopic total extraperitoneal mesh repair was performed. Intraoperative findings confirmed bilateral obturator herniae as well as incidental bilateral femoral herniae. This case highlights the need for a high index of suspicion for such concomitant hernias that, in the presence of OH, may only be identified intraoperatively.