Hernia obturatriz: Aspectos clínicos, imagenológicos y tratamiento / Obturator hernia: Clinical, imaging and treatment aspects

Introducción. Debido a la rareza de la hernia obturatriz y la imposibilidad para desarrollar estudios controlados de alto grado de evidencia, la mayoría de la literatura al respecto proviene de reportes de casos. Lo anterior, aunado al poco conocimiento del área anatómica de presentación y el cuadro clínico, la convierte en la hernia con mayor mortalidad. Métodos. Se realizó una búsqueda de la literatura en las principales bases de datos, ilustrado con pacientes manejados en el Servicio de Cirugía general de la Clínica Santa María de Sincelejo, Colombia. Discusión. La hernia obturatriz se puede descubrir en mujeres ancianas con antecedentes de cirugía abdominal o multiparidad. El signo de Howship­Romberg, que se presenta en la mitad de los pacientes, puede acompañarse de dolor abdominal en hipogastrio, vómitos y distensión progresiva. La radiografía de abdomen simple muestra tardíamente niveles hidroaéreos con ausencia de gas en ampolla rectal, pero como es poco específica para demostrar el sitio de obstrucción, es preferible la Tomografía computarizada. Conclusión. La hernia obturatriz requiere alto índice de sospecha, que ayude a la detección temprana e intervención quirúrgica inmediata, para evitar las complicaciones.

Introduction. Due to the rarity of the obturator hernia and the impossibility to develop controlled studies with a high degree of evidence, most of the reference in the literature comes from case reports. This, coupled with little knowledge of the anatomical area of presentation and clinical picture, makes it the hernia with the highest mortality. Methods. A literature search was carried out in the main databases, illustrated with patients managed in the General Surgery Service of the Clínica Santa María de Sincelejo. Discussion. Obturator hernia can be discovered in elderly women with a history of abdominal surgery or multiparity. The Howship ­ Romberg sign occurs in half of the patients, it can be associated with lower abdominal pain, vomiting, and progressive distension. Plain abdominal X-ray shows delayed air-fluid levels with absence of gas in the rectal ampulla, but since it is not very specific to demonstrate the site of obstruction, computed axial tomography is preferable. Conclusion. Obturator hernia requires a high index of suspicion, which helps early detection and immediate surgical intervention, to avoid complications.

Obstructed Obturator Hernia: A Diagnostic Dilemma.

Obturator hernia is a rare type of pelvic hernia which accounts for less than 1% of all abdominal hernias. It generally occurs in elderly emaciated patients with accompanying diseases. Because it is difficult to diagnose before surgery, the morbidity and mortality rates for obturator hernia are high. The most common clinical symptom is strangulation combined with mechanical intestinal obstruction. Abdominal CT scan can precisely confirm the diagnosis and early surgical intervention is essential for better outcome.

A Case of End-stage Cervical Cancer Complicated by Obturator Hernia That Was Difficult to Differentiate from Neuropathic Pain Due to Recurrent Pelvic Cancer

<p>Herein, we report our experience of a patient whose recurrent pelvic cancer was complicated by obturator hernia after cervical cancer surgery. Regardless of the type of carcinoma, recurrent pelvic cancer tends to be complicated by neuropathic pain. On the other hand, obturator hernia is also often complicated by the similar neuropathic pain, which is referred to as Howship-Romberg symptom. However, it is relatively a rare disease that is considered difficult to make a diagnosis. In the case of this report, the patient had already developed neuropathic pain in the inside of the left thigh when she was admitted to our hospital, and began to develop a similar symptom on the right side during the course of follow-up. Despite the additional administration of analgesic adjuvant, the pain in the right thigh did not improve, and she began to develop heat sensation and redness in the extensive area from the thigh to the knee. CT scan revealed subcutaneous emphysema image and abscess formation. Based on the results of the examination, the patient’s right thigh was diagnosed as caused by the digestive tract incarcerated by obturator hernia rupturing into the right limb. The differentiation of obturator hernia is difficult to make, but its early stage diagnosis might make it possible to evade the aggravation of the symptom by manual reposition. In conclusion, when recurrent pelvic cancer was found to be complicated by neuropathic pain, it is critical to make an appropriate diagnosis taking into account the potential obturator hernia at an early stage.</p>

Rol de la TC multicorte con RMP en el diagnóstico de la hernia obturatriz: presentación de un caso / Role of multislice CT with MPR (multi-planar reformation) in the diagnosis of obturator hernia. a case report

La hernia obturatriz (HO) es poco frecuente y representa del 0.05 al 0.4 por ciento del total de hernias. Debido a su rareza y a su presentación inespecífica, el diagnóstico es por lo general tardío y las tasas de mortalidad elevadas (12-70 por ciento). Se presenta un caso típico de HO diagnosticada en el preoperatorio mediante TC Multi-corte con RMP y tratado mediante laparotomía de urgencia con buen resultado. El empleo de TC Multicorte con RMP de abdomen y pelvis, en cuadros de obstrucción intestinal en mujeres añosas, sin antecedente de cirugías previas ni hernias objetivables, tiene gran valor para el diagnóstico preoperatorio precoz de HO y podría contribuir a reducir las elevadas tasas de morbilidad y mortalidad.

Abstract. The obturator hernia (OH) is rare and accounts for 0.05 to 0.4% of all hernias. Because of its rarity and its nonspecific presentation, diagnosis is usually late and has high mortality rates (12-70%). A typical case of OH diagnosed preoperatively by Multislice CT with MPR and treated using emergency laparotomy with good results, is presented. The use of Multislice CT with MPR of the abdomen and pelvis, in symptoms of intestinal obstruction in elderly women with no history of previous surgery or objectified hernias, has great value for early preoperative diagnosis of OH and could help reduce the high rates of morbidity and mortality.

Two Different Surgical Approaches for Strangulated Obturator Hernias

Obturator hernia is a rare condition that may present in an acute or subacute setting in correlation with the degree of small-bowel obstruction. Pre-operative diagnosis is difficult, as symptoms are often non-specific. A high index of suspicion should be maintained for emaciated elderly women with small-bowel obstruction without a previous abdominal operation and a positive Howship–Romberg sign. When diagnosis is in doubt, computed tomography scan of the abdomen and the pelvis (if available) or laparotomy should be performed immediately, as high mortality rate is related to the perforation of gangrenous bowels. We present 2 cases of strangulated obturator hernia, managed differently with both open and laparoscopic approaches. The diagnostic accuracy of computed tomography scan is highlighted followed by a brief literature review with an emphasis placed on surgical management.

Obstrucción intestinal por hernia obturatriz: caso clínico / Intestinal obstruction caused by an obturator hernia: report of one case

We report a 76 years old female presenting in the emergency room with a history of abdominal pain lasting seven days. A plain abdominal X ray showed few fluid filled loops. Due to persistence of pain and appearance of vomiting, an abdominal CAT sean showed a short bowel obstruction caused by an obturator hernia. The patient was operated, correcting the defect with a mesh. The postoperative evolution was uneventful.

La hernia obturatriz es una rara causa de obstrucción intestinal, se presenta en pacientes mujeres adultos mayores, desnutridos y postrados; se asocia a una elevada mortalidad por los antecedentes mórbidos de los pacientes y al bajo índice de sospecha. Se recomienda el uso de la tomografía axial computada como técnica de elección para el diagnóstico en pacientes con sospecha clínica. El objetivo de este trabajo es presentar un caso clínico de una paciente con hernia obturatriz que consultó en nuestro servicio de urgencia y se solicitó tomografía de abdomen y pelvis para completar estudio que requirió laparotomía exploradora ante el cuadro clínico y los hallazgos imagenológicos.

Diagnóstico y tratamiento de la hernia obturatriz: análisis de nuestra experiencia / Diagnosis and management of obturator hernia: analysis of our experience

Background: Obturator hernia is a rare type of hernia. Because symptoms and signs are non-specific, diagnosis and treatment are often delayed, increasing the rate of strangulation and mortality. Material and Methods: A retrospective study was performed in 17 cases of obturator hernia at Ramón y Cajal Hospital between January 1986 and December of 2007. Results: All patients were women with a mean age of 77 years (range 19-88 years). Mean time from onset of symptoms to surgery was 3 days (range 0-10 days). Howship-Romberg sign was positive in five cases (29,4 percent). Emergency surgery was performed in 16 cases (94 percent) and elective surgery in one (6 percent). CT has increased the rate of preoperative diagnosis from 16,6 percent to 41,2 percent, however, the rate of strangulation of bowel was 47 percent, requiring intestinal resection ten patients (59 percent). Hernia repair was performed using polypropylene mesh in 8 cases (47 percent) and by means of simple suture and apposition of the peritoneum in the rest 9 cases. Mean hospital postoperative stay was 11,65 days (range 4-26 days) and mortality was 23,5 percent. Conclusion: Although CT sean has facilitated us the correct diagnosis of obturator hernia, decreasing the mean time from onset of symptoms to surgery to 3 days, we could not reduce the rate of intestinal resection and mortality.

La hernia obturatriz es una entidad rara, con frecuente ausencia de signos y síntomas específicos, lo que retrasa su diagnóstico y tratamiento, y por ello puede presentar una elevada tasa de estrangulación y mortalidad. Material y Métodos: Efectuamos un estudio retrospectivo sobre 17 casos de hernia obturatriz en el Hospital Ramón y Cajal entre enero de 1986 y diciembre de 2007. Resultados: Todos los pacientes eran mujeres con una edad media de 77 años (rango 19-88 años). El tiempo medio desde el inicio de los síntomas hasta la cirugía fue de 3 días (rango 1-10 días). El signo de Howship- Romberg fue positivo en 5 casos (29,4 por ciento). Se efectuaron 16 intervenciones con carácter de urgente (94 por ciento) y una de forma electiva (6 por ciento). La realización de un TAC va a incrementar la tasa de diagnóstico preoperatorio de un 16,6 por ciento a un 41,2 por ciento. La tasa de estrangulación fue de 47 por ciento, requiriendo resección intestinal 10 pacientes (59 por ciento). En 8 ocasiones se reparó el defecto hemiario con una malla de polipropileno (47 por ciento), siendo con cierre simple y aposición del peritoneo en los 9 restantes. La estancia media postoperatoria fue de 11,65 días (rango 4-26 días) y la tasa de mortalidad de 23,5 por ciento. Conclusión: Aunque la realización del TAC ha incrementado la tasa de diagnóstico preoperatorio, disminuyendo el tiempo desde la aparición de los síntomas hasta la cirugía a 3 días, no hemos podido reducir la tasa de resección intestinal y mortalidad.

The Obturator Hernia: A Challenge for Early Diagnosis with Computed Tomography in Emergency Situations

Obturator hernias usually occur in elderly persons. We sometimes miss the correct diagnosis because of vague symptoms and signs in older patients at initial presentation. For good clinical outcomes, we should make the correct diagnosis earlier, especially in aged patients. Here we report cases of obturator hernia in two aged patients without specific medical or surgical histories. Two older women suffered obturator hernias, which were characterized by clinical and radiographic features. They did not have any specific surgical and medical histories. For further evaluation of abdominal symptoms and signs, we did an abdominopelvic computed tomography (CT) scan in the emergency department. The CT scan revealed findings compatible with an obturator hernia in the area of the obturator foramen. They were treated and discharged without complications. When obturator hernia is suspected in a patient with related symptoms and signs, early CT scans should be considered to detect obturator hernia.

Experiences on Obturator Hernia and Review of Korean Cases

PURPOSE: We performed this study to share experiences in the management of obturator hernia, which is a very rare disease among elderly women, because rarity of this disease will not approve an expert institute or surgeon and because the aging society, Korea, can increase the incidence. METHODS: Patient characteristics, clinical manifestations and treatment results were retrospectively collected from the 12 obturator hernia patients since 2000 in the three hospitals of the authors. Twenty-one obturator hernia cases reported in the Korean literatures were reviewed. In addition, we analyzed clinical features and treatment results of the total 33 patients, collectively. RESULTS: Most of the patients were elderly women except one young, poorly nourished, male patient with pulmonary tuberculosis. Their mean age was 79.6 years. Sixty-four percent (21/33) of the patients had preoperative morbidity. Symptoms from the compression of the obturator nerve, which is an important clue to the diagnosis, were observed in 67% (22/33). Interestingly, spontaneous or suspicious-spontaneous reductions were reported in 7 (21%) patients. Abdominal CT scan was the major tool for diagnosis. Abdominal approach alone could successfully manage most cases, though 84% (27/32) needed anastomosis of the bowel. Operative mortality was 2 of the 32 cases but morbidity was 44% of the 32 patients and the mean hospital period after operation was 21 days. CONCLUSION: Management of patients with obturator hernJd surgical management and proper peri-operative care as well as appropriate managing the families is essential for improved results.

Incarcerated Obturator Hernia: The Need of Herniorrhaphy in Self-reduced Obturator Hernia

An obturator hernia is an exceptionally rare form of hernia. It occurs mostly in elderly, thin, multiparous, and emaciated women. Correct diagnosis and treatment is important because delayed treatment can lead to a higher mortality rate. Recently, we experienced two cases of mechanical small bowel obstruction due to incarcerated obturator hernia. One of these patients was an 83-year-old woman who was diagnosed with left incarcerated obturator hernia by computed tomography (CT). The patient's symptom disappeared abruptly. A recheck CT scan revealed self-reduction of the obturator hernia, and the patient refused operation. Two weeks later, the patient was presented again to the emergency clinic with incarcerated small bowel in the left obturator hernia, which was seen on CT. The other patient was a 79-year-old woman who had a 2-day history of abdominal pain. She was diagnosed with a right obturator hernia by CT. Both patients were treated without bowel resection.

Successfully Treated Obturator Hernia in Spite of Delayed Operation

Obturator hernia is a rare type of pelvic hernia and occurs most commonly in elderly and debilitated women. It is still a challenge for surgeons to diagnose precisely in early stages because of its nonspecific symptoms and consequently delayed diagnosis could lead to high morbidity and mortality. We experienced a 92-year old patient who was diagnosed as obturator hernia which was confirmed by computed tomography scan of the abdomen and pelvis. The operation was delayed due to the refusal of family members but eventually done after 12 days from initial diagnosis. After manual reduction of small bowel impacted into right obturator foramen, segmental resection of impacted small bowel and anastomosis was done. The hernial defect was closed by primary closure with Dexon suture material. After the operation, the patient was discharged without significant complications. We report here successful results of delayed operation for obturator hernia.

Totally Extraperitoneal Laparoscopic Repair of Obturator Hernia withPartial Intestinal Obstruction

Obturator hernia is a rare variety of pelvic hernia. The diagnosis frequently is delayed and may be accompanied by dehydration, acute abdominal distress and small bowel strangulation. We report a case of totally extraperitoneal repair of obturator hernia with partial intestinal obstruction. An eighty-two-year old female with intermittent abdominal pain was diagnosed with obturator hernia with partial intestinal obstruction. We did total extraperitoneal laparoscopic repair of the obturator hernia with polypropylene mesh. Total extraperitoneal laparoscopic repair for obturator hernia is a safe and effective treatment.

Small Bowel Obstruction due to Incarcerated Obturator Hernia

An obturator hernia is a rare but important cause of small bowel obstruction, due to the difficulty of its diagnosis and the high mortality rate. Elderly, multiparous and debilitated women with comorbid illnesses are most often affected, and this hernia, coupled with a delay in the diagnosis and operative intervention, results in the high mortality rate, which represents both diagnostic and therapeutic challenges to the surgeon. Recently, we experienced two unusual obturator hernia cases, where incarceration had lead to a small bowel obstruction. One patient was an 82-year-old woman with a compression fracture of the lumbar spine, which presented with left inguinal pain and abdominal distension. The abdominal plain X-ray showed evidence of a small bowel obstruction. The hernia was diagnosed by a computed tomography (CT) scan and repaired using the lower midline transperitoneal approach. To prevent a recurrence, the hernial defect was enforced with a polypropylene plug and mesh. The other patient was a 92-year old woman with fracture of the neck of the left femur, which presented with defecation difficulty and abdominal distension. The abdominal plain X-ray showed multiple distended small bowel loops consistent with small bowel obstruction. A contrast-enhanced CT scan of the abdomen and pelvis showed a right obturator hernia with strangulation. We recommended an emergency operation, but the patient refused the operative procedure. With on going conservative management, the symptom was fortunately resolved. Herein, we report these findings with a brief review of the literature.

Obturator Hernia Which was Combined with Inguinal Hernia and Hiatal Hernia

Obturator hernia is a rare type of hernia, which is difficult to detect early because of its nonspecific symptoms. A delayed diagnosis could lead to high morbidity and mortality. We experienced an unusual patient who had multiple hernias including an obturator hernia. A very thin 85-year-old woman visited hospital complaining of pain in the right thigh and knee. One week later, she was admitted again due to whole abdominal pain and vomiting. The abdominal simple radiographs showed a small bowel obstruction. On Abdominal CT, a herniated small bowel was located between the right pectineus muscle and the right external obturator muscle. A concomitant right inguinal hernia, which contained fatty tissue, was observed. A coincidental hernia of the stomach into left chest was also noted. Laparotomy revealed a strangulated small bowel in a right-sided obturator foramen and an impacted omentum in a right-sided inguinal canal. The terminal ileum was perforated at the proximal site from the incarcerated portion. A 10 cm length ileum including the perforation site was resected, which was followed by a primary anastomosis. The hernial defect was closed with a prosthetic mesh plate. In conclusion, the use of a of permanent mesh in an obturator hernia is a adequate method for closing an obturator hernia.

Strangulated Obturator Hernia: Mesh-Plug Technique

Although obturator herniae are rare, they are associated with a high mortality, as diagnosis is often delayed and the condition tends to occur in the elderly. The preoperative diagnosis is difficult because of nonspecific symptoms and sign. They often produce a small bowel obstruction. The treatment is always surgical. Several repair techniques have been described: a sac ligation alone, a direct suture repair, and the use of autologous tissue or prosthetic repair. Recently, the placement of permanent mesh prostheses, in a clean contaminated operative field, has been performed due to the minimal wound-related morbidity and patient mortality. Thus, utilization of a permanent mesh in an obturator hernia is a new, simple and effective method for repair. Two cases of a strangulated obturator hernia were experienced in elderly women. The peritoneal cavity was not overly contaminated, with only necrotic foci on the herniated small bowel wall noted. A segmental resection of the small bowel was performed. Consequently, the hernia defect was closed with mesh- plug between the peritoneum and periosteum of the obturator foramen. Here, two cases of obturator herniae treated by use of a mesh-plug are reported, with a brief review of the literature.

Recurrent Strangulated Obturator Hernia

An obturator hernia is a rare condition, occurring most frequently in elderly and debilitated women. The diagnosis is difficult, and delayed treatment is associated with serious complications. In most cases, it produces a small bowel obstruction with high morbidity and mortality. We experienced an unusual case of a left recurrent obturator hernia. The patient was a 76-year-old woman with atrial fibrillation, presented with intermittent generalized abdominal pain and distension. The patient underwent a laparotomy because of a left incarcerated obturator hernia 2 years ago. The abdominal plain X-ray showed evidence of a small bowel obstruction. A CT scan established a correct diagnosis. Consequently, the patient underwent an immediate laparotomy. There were a few necrotic foci on the herniated small bowel wall. Therefore, a segmental resection of the small bowel was performed. To prevent a recurrence, the hernial defect was closed with several interrupted sutures between the peritoneum and periosteum of the obturator foramen. As patients with an obturator hernia are almost elderly women, and often have multiple concurrent medical problems. An immediate CT scan of the abdomen, including the pelvic area, should achieve an early diagnosis. Early surgical intervention should be done without serious medical diseases. Besides definitive surgery is needed to prevent a recurrence.

Preoperative Diagnosis of Strangulated Obturator Hernia Using CT

Obturator hernia is a rare pelvic hernia, occuring most frequently in elderly, debilitated women. Because of nonspecific symptoms, the diagnosis of obturator hernia is often delayed until laparotomy for bowel obstruction. This leads to high bowel resection and mortality rates, which represents a diagnostic and therapeutic challenge for surgeons today. We experienced an unusual case of right obturator hernia with strangulation in an 81-year-old female patient who presented with intermittent generalized, particularly right lower quadrant, abdominal pain and distension. The hernia was diagnosed by computed tomography (CT) scan and repaired using the lower midline transperitoneal approach. CT scan in the evaluation of patients with nonspecific intermittent gastrointestinal symptoms leads to a diagnosis of occult hernia. We report these findings with a brief review of the literature focusing on finding indicators leading to early diagnosis and treatment.

Strangulated Obturator Hernia

An obturator hernia is an extremely rare rupture that protrudes through the canal that transmits the obturator vessels. We performed computed tomography of the abdomen and pelvis on two elderly debilitated women patients with small bowel obstructions to make a correct diagnosis. We report these with a brief review of the literature.