Incarcerated obturator hernia, an extremely rare cause of intestinal obstruction: case series.

Protrusion of abdominal contents through the obturator foramen is a rare type of abdominal wall hernia. It is usually seen unilaterally and right-sided. Predisposing factors are old age, high intra-abdominal pressure, pelvic floor dysfunction, and multiparity. Obturator hernia has one of the highest mortality rates of all abdominal wall hernias, with a difficult diagnostic process that can be misleading even for the most experienced surgeons. Therefore, to suspect and easily diagnose an obturator hernia, it is important to understand its characteristics. Computerized tomography scanning remains the best diagnostic tool with the highest sensitivity. Conservative ap-proach is not recommended in obturator hernia cases. Once diagnosed, urgent surgical repair is indicated to prevent further ischemia, necrosis, and risk of perforation that can lead to peritonitis, septic shock, and death. Although open repair is a widely used and effective method for reducing abdominal hernias, including obturator, laparoscopic repairs have been described and become preferred. In this study, we present female patients aged 86, 95, and 90 years who were operated with the diagnosis of obturator hernia on computed tomography. The diagnosis of obturatory hernia should always be kept in mind, especially in the presence of acute mechanical intestinal obstruction findings in an elderly woman.

Mechanical intestinal obstruction in underweight, elderly women due to an incarcerated obturator hernia.

BACKGROUND: Obturator hernia is an infrequent pelvic hernia observed in elderly, emaciated and multiparous women. It often presents with nonspecific clinical symptoms, making it difficult to diagnose. METHODS: We conducted a retrospective descriptive study on 11 patients admitted to our hospital for obturator hernia from 2009 to 2020. RESULTS: All the patients were diagnosed with intestinal obstruction due to incarcerated obturator hernia preoperatively. Eight patients underwent laparotomy with low midline incision. Laparoscopic approach was tried on the other three patients with two patients converting to open surgery because of inadequate visualization, and only one patient received laparoscopic repair. Of the 10 patients receiving laparotomy, seven cases received obturator hernia repair with a match and three cases were subjected to bowel resection (two cases intestinal necrosis and one case intestinal perforation). Simple peritoneal closure was performed on the three contaminated cases. One patient died of septic shock and multiple organ failure. CONCLUSION: The emergent computed tomography allow for early and precise diagnosis of incarcerated obturator hernia. Laparotomy with low midline incision is commonly used to manage obturator hernia in an emergency, whereas laproscopic approach may only apply to some selected cases.

Early CT Ameliorates the Diagnostic Dilemma of "Little Old Lady's Hernia": A Case Report.

Encountering an obturator hernia itself is a rare entity for practicing surgeons globally. Synonymously known as the "old lady's hernia" is usually seen in fragile geriatric multiparous female patients. We share our experience of this rare entity where the patient presented with features of small bowel obstruction. Her diagnosis was delayed in the previously attended other centre as the possibility of an obturator hernia was overlooked. A timely clinical examination of the patient complemented by a computed tomography scan of the abdomen and pelvis helped us to obtain a diagnosis and proceed with immediate surgery. Intraoperatively the rarity was present bilaterally although the obstruction was on one side only. Prompt diagnosis and treatment benefits patients in this potentially lethal condition. Keywords: case report; computed tomography; obturator hernia; X-ray.

Obturator hernia: a case report.

BACKGROUND: Obturator hernia is rare and accounts for less than 1% of all abdominal wall hernias. It represents a diagnostic challenge due to its nonspecific signs and symptoms. CASE PRESENTATION: We present a case of an 89-year-old caucasian female with a 12-hour history of right medial thigh pain. Computed tomography scan revealed a right obturator hernia with small bowel obstruction. The hernia was successfully repaired laparoscopically without any need for small bowel resection. She was discharged on postoperative day 2 with an uneventful recovery and zero complications. CONCLUSION: This case report highlights the importance of rapid diagnosis and repair of obturator hernia even in the setting of an improving clinical picture. It also demonstrates the safety of laparoscopic repair in this setting.

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.

Obturator hernia of Richter type: a diagnostic dilemma.

An 85-year-old malnourished woman presented with symptoms of small bowel obstruction of uncertain aetiology. She had presented numerous times over the previous 2 years with symptoms of left groin and thigh pain, vomiting and abdominal distension. A CT of her abdomen and pelvis ultimately revealed a left-sided pelvic hernia, between the obturator internus and pectineal muscles. This was consistent with an obturator hernia. Diagnostic laparoscopy confirmed an obturator hernia of Richter type, incarcerated within the left obturator canal. Reduction revealed a hernia sac containing viable small bowel. A primary repair was performed using a double-layer suture technique to both close and plug the hernia defect. The patient rapidly recovered following hernia repair, with resolution of all previous long-standing symptoms. This case exemplifies the typical presentation of an obturator hernia and the diagnostic challenge it poses to clinicians.

Diagnostic difficulties in obturator hernia: a rare case presentation and review of literature.

Hernia arising from obturator canal is rare and it contributes to about less than 1% of incidence of all hernias. Diagnosing an obturator hernia clinically is a challenging one and nearly impossible. These hernias usually present as an intestinal obstruction as more than 50% of obturator hernias goes in for strangulation. Here, we report an unusual presentation of an obturator hernia in a 70-year-old woman who presented to emergency room with acute abdomen and uncomplicated reducible inguinal hernia. Radiological imaging showed obstructed inguinal hernia while on diagnostic laparoscopy, a strangulated and perforated obturator hernia of Richter's type was seen in addition to an uncomplicated inguinal hernia. Obturator hernia, although very rare, is associated with high morbidity and mortality as it is often underdiagnosed as in our case. Laparoscopy bailed us out from missing out a perforation from an occult obturator hernia.

Obturator hernia presenting partial obstruction in an elderly patient.

Obturator hernia (OH) is a relatively rare pelvic hernia. OH is usually seen in elderly, multiparous females and patients with a low body weight. Obturator hernia accounts for 0.07-0.4% of all intraabdominal hernias and 0.2-5.8% of small bowel hernias. The diagnosis of obturator hernia can be difficult and often delayed. Any therapeutic delay is associated with serious complications and higher mortality rates. The correct preoperative diagnosis of obturator hernia is facilitated by computed tomography (CT). Our case was admitted to our emergency unit with intolerance to oral intake for one week. Abdominal ultrasonography was not helpful. The CT of the abdomen revealed the incarcerated intestinal segment. Diagnostic laparoscopy confirmed the CT findings. The intestine was gangrenous and perforated. Segmental resection and anastomosis was performed. Early diagnosis and surgical intervention are essential. This demonstrates that emergency CT scan is useful for the diagnosis of obturator hernia in patients presenting with mechanical intestinal obstruction of unknown origin.

Subacute Bowel Obstruction Secondary to an Obturator Hernia.

Obturator hernia is a rare abdominal wall hernia and is one of the rare causes of intestinal obstruction. Due to lack of specific clinical symptoms in the early stage, and the deep position of hernia absence of surface swelling, few cases are diagnosed definitively before surgery. Therefore, obturator hernia is still a serious disease in clinical practice, with high mortality and morbidity. Herein, we report an 85-year female who was hospitalised with bowel obstruction. Preoperative computed tomography scan was performed, which revealed an incarcerated obturator hernia preoperatively; and it was treated successfully. This report reviews the diagnosis and treatment of obturator hernia by describing its anatomy, clinical manifestations and clinical signs. Increased awareness and proper management of the disease will lead to a decline in mortality and morbidity.

Radiographic and surgical findings of type I obturator hernias in patients with refractory groin pain.

Groin pain is a common complaint in the general population, with an underlying etiology that may be difficult to diagnose. Although uncommon, type I obturator hernias may be a significant source of chronic or refractory groin pain. In this review, we discuss the commonly missed findings of type I obturator hernias at CT and MRI, as well as correlate these findings with images obtained at the time of laparoscopic repair.

Análisis de nuestra experiencia en el diagnóstico y tratamiento de la hernia obturatriz en un hospital de tercer nivel / Analysis of our experience in the diagnosis and treatment of obturator hernia in a third level hospital

La patología herniaria supone un porcentaje importante de las intervenciones quirúrgicas urgentes. La hernia obturatriz es una entidad poco frecuente, presentándose generalmente como un cuadro de oclusión intestinal agudo en mujeres adultas. El objetivo del estudio es analizar la experiencia en un hospital de tercer nivel en el diagnóstico y tratamiento de la hernia obturatriz, así como detectar aquellos signos que permitan un diagnóstico precoz. La técnica de imagen de elección para su diagnóstico es la tomografía computarizada. Se trata de un estudio observacional prospectivo, en el que se incluyeron pacientes intervenidos de forma urgente por hernia obturatriz entre los años 2000 y 2016. Para el registro de la morbilidad postoperatoria se empleó la clasificación de Clavien-Dindo. Se identificaron doce pacientes con clínica de obstrucción intestinal secundaria a hernia obturatriz. Todos ellos fueron intervenidos de forma urgente, realizándose laparotomía media urgente en el 59%, laparotomía media infraumbilical en el 33% y abordaje por vía inguinal posterior en un solo paciente (8%). En ocho pacientes (67%) fue necesario realizar una resección intestinal por isquemia intestinal. La técnica quirúrgica empleada fue la reparación mediante malla de polipropileno en seis pacientes (50%), mediante tapón en dos (17%) y cierre con puntos sueltos en cuatro (33%). Cuatro de ellos presentaron complicaciones postoperatorias, registrando un único exitus secundario a perforación por sufrimiento intestinal. Es prioritario establecer un diagnóstico precoz y tratamiento quirúrgico urgente para reducir la morbimortalidad asociada a la hernia obturatriz

Hernia pathology accounts for a large percentage of urgent surgical interventions. Obturator hernia is rare, usually presenting as a picture of acute intestinal occlusion. The aim of the study is to analyze the experience in a third level hospital in the diagnosis and treatment of obturator hernia, as well as to detect those signs that allow an early diagnosis. This is a prospective observational study, which included patients operated on urgently for obturator hernia between 2000 and 2016. For the registration of postoperative morbidity, the Clavien-Dindo classification was used. We identified twelve patients with intestinal obstruction secondary to obturator hernia. All of them were operated on urgently. Urgent midline laparotomy was carried out on 59% of them, infraumbilical laparotomy on 33%, and a posterior inguinal approach was realized on only one patient (8%). In eight patients (67%) it was necessary to perform intestinal resection. Repair was performed by polypropylene mesh in six patients (50%), by plugging in two (17%) and closing with loose stitches in four patients (33%). Four of them presented postoperative complications, recording a single exitus secondary to perforation due to intestinal suffering. Obturator hernia is a rare entity that develops mostly as an occlusive condition in elderly women. The imaging technique of choice for diagnosis is computed tomography. Establishing an early diagnosis and urgent surgical treatment is a priority to reduce associated morbidity and mortality

[Analysis of our experience in the diagnosis and treatment of obturator hernia in a third level hospital]. / Análisis de nuestra experiencia en el diagnóstico y tratamiento de la hernia obturatriz en un hospital de tercer nivel.

Hernia pathology accounts for a large percentage of urgent surgical interventions. Obturator hernia is rare, usually presenting as a picture of acute intestinal occlusion. The aim of the study is to analyze the experience in a third level hospital in the diagnosis and treatment of obturator hernia, as well as to detect those signs that allow an early diagnosis. This is a prospective observational study, which included patients operated on urgently for obturator hernia between 2000 and 2016. For the registration of postoperative morbidity, the Clavien-Dindo classification was used. We identified twelve patients with intestinal obstruction secondary to obturator hernia. All of them were operated on urgently. Urgent midline laparotomy was carried out on 59% of them, infraumbilical laparotomy on 33%, and a posterior inguinal approach was realized on only one patient (8%). In eight patients (67%) it was necessary to perform intestinal resection. Repair was performed by polypropylene mesh in six patients (50%), by plugging in two (17%) and closing with loose stitches in four patients (33%). Four of them presented postoperative complications, recording a single exitus secondary to perforation due to intestinal suffering. Obturator hernia is a rare entity that develops mostly as an occlusive condition in elderly women. The imaging technique of choice for diagnosis is computed tomography. Establishing an early diagnosis and urgent surgical treatment is a priority to reduce associated morbidity and mortality.

Midline Extraperitoneal Approach for Obturator Hernia Repair.

Obturator hernia (OH) is a rare condition that accounts for 0.073-1% of abdominal hernias and 0.48% of bowel obstructions. OH frequently occurs in elderly women, with an incidence that increases with age. The only treatment for OH is surgical intervention, and the approaches used vary greatly. Consequently, a well-defined consensus has not yet emerged. We assessed the efficiency and safety of the midline extraperitoneal approach for OH. Six patients with OH repaired using the midline extraperitoneal approach at KKR Sapporo Medical Center between April 2011 and January 2016 were included in the study. We retrospectively evaluated the patient characteristics, intraoperative findings, and the postoperative course. All patients were elderly women [median age, 90 (range, 79-92) years], with a median body mass index of 17.0 (range, 15.6-18.3) kg/m2 at presentation. All had symptoms associated with bowel obstruction: two patients presenting with leg pain had the Howship-Romberg sign. In two patients, bowel resection was required because of irreversible ischemic changes. Five patients had coexisting femoral and inguinal hernias that were repaired by bilateral mesh repair. One patient had aspiration pneumonia as a postoperative complication. All patients were discharged alive, without infection or recurrence. OH can be efficiently and safely repaired using the midline extraperitoneal approach. This approach establishes the diagnosis of OH, avoids injuring obturator vessels, gives improved exposure of the obturator canal, enables identification and simultaneous repair of other pelvic hernias, and facilitates bowel resection. This approach reduces the risk of mesh infection in patients undergoing bowel resection.

Incarcerated obturator hernia treated using a hybrid laparoscopic and anterior preperitoneal approach: A case report.

Obturator hernia (OH) is a rare cause of bowel obstruction. Although several surgical approaches, including the laparoscopic approach, have been reported to date, a standard approach for treating OH has not been established. A 101-year-old woman who presented with constipation and vomiting was admitted to our hospital. CT revealed an incarcerated small bowel within the left obturator foramen, and a diagnosis of left-sided incarcerated OH with small bowel ileus was made. With the patient under general anesthesia, exploratory laparoscopy was performed; we identified an OH with an incarcerated small bowel, which was judged viable after hernia reduction. We repaired the hernia using an anterior preperitoneal approach under laparoscopic assistance and placed a prosthetic mesh over the obturator foramen. The patient recovered with no postoperative complications and was discharged on postoperative day 4. A hybrid laparoscopic and anterior preperitoneal approach is safe and effective for treating an incarcerated OH in an elderly patient.

Efficacy of emergency exploratory laparotomy in incarcerated obturator hernia.

BACKGROUND: Incarcerated obturator hernia (IOH) is a scarce type of acute surgical disease, but the mortality rate is the highest in abdominal hernias. The aim of this study was to evaluate the efficacy of emergency exploratory laparotomy (EEL) in treating incarcerated obturator hernia (IOH). METHODS: We conducted a retrospective study of 12 female patients with IOH underwent EEL between January 2014 and March 2016. The variables which included patient characteristics, findings of CT, operative time, postoperative complications, length of hospital stay, ICU admission rate, 30-day readmission rate and mortality were analyzed. RESULTS: The age of patients was 82.5 ± 4.2 years and the median body mass index (BMI) was 20.6 kg/m2 (IQR, 18.7-21.5 kg/m2). There were 10 patients (83.3%) underwent partial intestinal resection due to partial small bowel necrosis or perforation. The total operation time was 85.7 ± 8.7 min. The time to initiation of a soft diet was 3.9 ± 0.7 days and the median length of stay was 15.0 days (IQR, 14.0-17.5 days), respectively. CONCLUSIONS: The EEL is a clinically safe and necessary choice for early diagnosis and treatment in IOH. EEL may improve the curative effect of IOH significantly.