Internal hernia beneath the obturator nerve after robot-assisted lateral lymph node dissection for rectal cancer: A case report and literature review.

A 63-year-old man who underwent robot-assisted laparoscopic low anterior resection and right lateral lymph node dissection (LLND) for rectal cancer presented with right thigh pain, nausea, vomiting, and abdominal pain on postoperative day 17. CT revealed dilated small bowel in the pelvis, and a small bowel loop was detected outside the internal iliac artery branch. Emergent laparoscopic surgery revealed the migration of the small bowel into the space beneath the right obturator nerve. The herniated bowel was reduced, and the obturator nerve was sharply dissected from the herniated bowel and preserved. The hernial orifice was left unrepaired. Postoperative recovery was uneventful, and the right thigh pain disappeared. It is important to consider the possibility of internal herniation beneath the obturator nerve after minimally invasive lateral lymph node dissection for rectal cancer.

Aggressive angiomyxoma of the pelvis presenting as an obturator hernia.

INTRODUCTION : Angiomyxoma is a rare slow-growing soft tissue myxoid cell tumor that usually arises in the pelvis and perineal regions and occurs predominantly in women in the fourth decade. Angiomyxomas usually present as often initially misdiagnosed asymptomatic masses. Most common clinical early diagnoses of aggressive angiomyxomas are in form Of Vulvar Masses, Vulvar Lipomas, Bartholin's Cysts, Levator Hernias, Inguinal Hernias Or Cervical Polyps. PATIENTS AND METHODS: This paper presents the case of the pelvic angiomyxoma diagnosis of a 41 year old with early findings of suspicious obturator hernia during the initial physical examination. RESULTS: The dissection was extended from the right retrorectal area to the ischiorectal cavity and the mass was reached. The capsulated mass of 10*15 cm with soft consistency was completely released and unblocked, it was excised from the abdomen through the incision using wound protection The obturator defect was repaired with interrupted sutures. CONCLUSIONS: Angiomyxoma is a rare, benign and locally aggressive tumor, which can infiltrate locally and present unusually as perineal hernia. Due to its rarity and lack of specific diagnostic requirements, it's difficult to diagnose preoperatively KEY WORDS: Angiomyxoma, Obturator hernia, Pelvic mass.

Obturator hernia--a condition seldom thought of and hence seldom sought.

PURPOSE: Obturator hernia is an extremely rare type of hernia with an incidence of less than 1% of all abdominal wall hernias occurring predominantly in elderly females characterized by protrusion of the intra-abdominal viscera into the obturator foramen. It presents with pain along the medial aspect of the thigh referred to the knee due to compressed obturator nerve and sometimes as an uncommon cause of intestinal obstruction. It remains a clinical diagnostic dilemma and often perplexing the decision for surgery. This explanatory review emphasizes and illuminates its various facets under the rationale of its diagnosis and management to familiarize surgeons with the condition. METHODS: The data for the present review was obtained by searching in PubMed and other databases using key terms "obturator hernia", "abdominal hernia", "intestinal obstruction", and "Howship-Romberg sign". Many original articles, reviews, and case reports were selected. RESULTS: Since it is very rare that a mass can be found on inspection of the medial aspect of the thigh and the clinical signs are not always present, hence obturator hernia is a condition which leads to both difficult and delayed clinical diagnosis and consequently having a significant morbidity and mortality rates, especially in the elderly. CONCLUSION: Obturator hernia should always be in the differential diagnosis in septuagenarian to nonagenarian patients with nonspecific signs and symptoms of intestinal obstruction. Computed tomography of abdomen and pelvis has been found to be the gold standard for preoperative diagnosis and this condition necessitates immediate surgical reduction and repair of the defect either by open or laparoscopic approach.

Strangulated obturator hernia - an unusual presentation of intestinal obstruction.

An 81-year-old Caucasian emaciated female presented with 3 days history of colicky abdominal pain nausea, projectile vomiting and abdominal distension. A pre-operative diagnosis of mechanical bowel obstruction was made. The absence of characteristic clinical signs in this thin elderly woman with a small bowel obstruction failed to provide a pre-operative diagnosis. She underwent a midline laparotomy and resection and anastomosis of small bowel and repair of the strangulated right obturator hernia. The high mortality rate associated with this type of abdominal hernias requires a high index of suspicion to facilitate rapid diagnosis and prompt surgical intervention if the survival rate is to be improved.

Obturator canal fat plug: a pre-hernial condition?

Although obturator hernias are rare, they are associated with a high mortality, as diagnosis is often delayed and the condition tends to occur in the elderly. Previous researchers have postulated that obturator hernias begin with invagination of pre-peritoneal fat through the pelvic orifice of the obturator canal, forming a fat plug. With chronically raised intra-abdominal pressure, or sudden weight loss, this can progress to a clinical obturator hernia. We dissected 95 Caucasian cadaveric hemi-pelvises (47 males; 48 females) in order to investigate the frequency of fat plugs and examine the validity of the current hypothesis regarding obturator hernia pathogenesis. The mean age (SD) of the specimens was 83 (9) years, with 48 (24 male; 24 female) from the left side and 47 (23 male; 24 female) from the right side. A fat plug was found in 21 canals (22%); the majority were female (71%, P = 0.03), and right sided (62%, P = 0.20). The mean (SD) length was 20.0 mm (6.3 mm), with mean diameter 5.9 mm (1.8 mm). A shallow peritoneal dimple was also found overlying fat plugs in two specimens. No visceral herniations were found. The sex and side distribution of the obturator canal fat plugs we found are similar to those of obturator hernias reported in the literature, supporting the hypothesis that fat plugs are pre-hernial. It is unlikely that fat plugs are a high-risk condition, but dimples over these plugs may be a marker of potential hernia formation.

Rare pelvic floor hernias. Report of a case and review of the literature.

The case of a 64-year-old female who presented with difficult evacuation of stool is reported. A posterior perineal hernia was diagnosed by dynamic proctography. The patient had an unusual herniation of the upper rectum through the perineal defect. At surgery, there was no peritoneal sac, since the herniation occurred extraperitoneally. The patient was treated with repair of the pelvic floor using Marlex mesh and rectopexy. Pelvic floor hernias are rare and often difficult to diagnose. The three types, in order of decreasing frequency, are obturator, perineal, and sciatic. The etiology, diagnosis, and treatment of each is discussed.

Recurrent strangulated obturator hernia.

A case of recurrent strangulated obturator hernia is presented. The difficulty in diagnosing obturator hernia and the high mortality associated with strangulation are highlighted from a literature review. A high index of suspicion in older patients presenting with intestinal obstruction without an obvious cause, possibly combined with CT scanning of the pelvic region, may lead to earlier diagnosis and operation and a more favourable outcome in such cases.

Chronic peritoneal dialysis: mechanical and infectious complications.

The present report summarizes the mechanical and infectious complications attributable to the devices and procedures used for chronic peritoneal dialysis (PD), comparing the type and frequency of such complications in contemporaneous groups of patients undergoing continuous ambulatory PD (CAPD) or intermittent PD (IPD). Mechanical complications related directly to the catheter and its placement proved to be equally frequent during CAPD and IPD. On the other hand, mechanical complications related to increased intraperitoneal pressure were more frequent during CAPD. In most instances mechanical complication can be managed without permanent interruption of chronic PD. Peritonitis occurs more frequently during CAPD (1.6 episodes per patient-year) than during IPD (0.4 episodes per patient-year), with a tendency to more frequent peritonitis among diabetics, children, patients with white blood cell abnormalities, patients with catheter cuff or tunnel inflammation, and during the 1st month of treatment. Medical therapy eradicates peritonitis and allows continuation of chronic PD with retention of the catheter in more than 90% of episodes, although special problems may be encountered with fungal, pseudomonal, and some coagulase-positive staphylococcal infections.