Time to symptom onset and manual reduction outcomes as predictors of bowel viability in incarcerated obturator hernias.

The current study aimed to identify the indications for manual reduction in incarcerated obturator hernias (OH). Further, whether time to symptom onset and manual reduction outcomes can be predictors of bowel viability and the need for bowel resection in incarcerated OH were examined. This retrospective study included 26 patients with incarcerated OH who underwent surgery. All patients underwent manual reduction, and computed tomography scan after manual reduction confirmed hernia release. Multivariate analyses were performed to determine the predictors of bowel resection. The bowel resection group had a significantly longer average time to symptom onset than the nonbowel resection group (88 vs 36 h). Further, the bowel resection group was more likely to have failed manual reduction than the nonbowel resection group. A time to symptom onset of ≥ 72 h and failed manual reduction were significant predictors of bowel viability. Age, sex, hernia localization, American Society of Anesthesiologists physical status score, and laboratory findings did not differ significantly between the bowel resection and nonbowel resection groups. Time to symptom onset and manual reduction outcomes are significant predictors of bowel viability in incarcerated OH. Patients with a time to symptom onset of ≥ 72 h and failed manual reduction require surgical evaluation due to a high risk of bowel nonviability. Therefore, a cautious approach is required in the management of OH, and further research on optimized treatment protocols should be conducted.

Obturator hernia: a persisting clinical diagnostic challenge - a case report.

Introduction: The presentation of a strangulated obturator hernia is rare, with it accounting for less than 0.04% of all hernias. Delay in presentation and diagnosis results in complications like bowel ischemia, necrosis, perforation, and peritonitis, thereby increasing morbidity and mortality. Case presentation: The authors report the case of an 85-year-old multiparous woman who presented with a 3-day history of abdominal pain and vomiting. Upon examination, she exhibited hypotension, altered sensorium, and a distended abdomen with visible peristalsis. An abdominal pelvic computed tomography scan confirmed the diagnosis of 'intestinal obstruction secondary to an incarcerated obturator hernia'. Subsequently, a lower midline laparotomy was performed, successfully reducing the bowel and repairing the hernial orifice. The patient was discharged on the fourth postoperative day, and there has been no hernia recurrence as of her 3-month follow-up. Discussion: The presentation of a strangulated obturator hernia can be elusive. During clinical examination, both the Howship-Romberg sign and the Hannington-Kiffs sign tests may be negative. Laparoscopic obturator hernia repair has been shown to reduce hospital stay and morbidity. A midline laparotomy has the advantage of easy manual reduction, minimizing bowel trauma, accurately accessing the bowel, and facilitating bowel resection. Conclusion: Obturator hernias constitute rare subtypes of abdominal hernias. They typically occur in older women, and patients often present with poor functional status and multiple comorbidities. The clinical diagnostic tests are uncertain, even in patients with a high index of suspicion. Timely diagnosis and appropriate surgical management are crucial for a favorable outcome.

Incarcerated obturator hernia with a fistula to the adductor muscles: Case report of a rare hernia with uncommon symptoms, discovered by CT.

INTRODUCTION: Obturator hernias are rare, occur mainly in slender people and predominantly in females. Underlying pathology of the obturator hernia is a weakening of the obturator membrane. The obturator hernia is situated between the pubic and ischial bones and is therefore clinically occult. Patients predominantly present with symptoms of bowel obstruction, but can also present with sensory disturbance, leg pain and hip pain. Due to the usually delayed diagnosis, the obturator hernia is associated with increased morbidity and mortality. CASE PRESENTATION: A 71-year-old female patient with hip pain underwent a protracted diagnostic work-up and was referred to the surgical department by the treating orthopedic surgeon. An incarcerated obturator hernia with a fistula in the adductor ligament was finally diagnosed via CT. The operation included laparoscopic reduction, hernia repair, open small bowel segment resection, local surgical exploration, lavage and antibiotic treatment. The primary hernia repair was performed by direct suture due to the contamination, and a post-primary mesh repair was indicated. However, after complete recovery and no remaining symptoms, the patient refused this despite the indication for definitive laparoscopic hernia repair. DISCUSSION: Hip pain can have multiple causes. Taking physical characteristics into account can lead to the correct diagnostic pathway. The CT scan revealed the fistula which led to the laparoscopic surgery. Due to the intestinal damage and contamination, the surgical steps were adapted. CONCLUSION: Obturator hernias should be considered as a reason for atypical symptoms in slender, older patients. Adequate surgical management can be chosen after correct diagnosis.

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.

Laparoscopic repair of concurrent direct and indirect inguinal, femoral, and obturator hernias on the same side: A case report.

Concurrent direct and indirect inguinal, femoral, and obturator hernias are rare. This case report describes a rare case treated using the laparoscopic approach. A 68-year-old female patient presented with a moving left inguinal lump and pain. Physical examination and abdominal computed tomography scan revealed the coexistence of a left inguinal hernia or Nuck canal hydrocele and a left femoral hernia. The patient underwent laparoscopic transabdominal preperitoneal repair, and all four orifices were covered with one mesh. The patient was discharged on the second postoperative day without any complications. The concurrent presence of four hernias on the same side is rare and has not been previously reported. The laparoscopic approach is useful in such cases because it allows visualization of multiple hernia orifices from the intra-abdominal cavity.

Acute Intestinal Obstruction Due to Obturator Hernia: A Case Series.

Most obturator hernias are diagnosed intraoperatively due to their vague signs and symptoms. However, they are associated with a high mortality rate mainly because of the patient's age, comorbidities, and late diagnosis. We present three cases of obturator hernia in patients admitted under our care with signs of acute intestinal obstruction. All the patients were elderly with comorbidities, and they underwent open surgery with anatomical repair of the hernial defect with or without resection of any gangrenous bowel. They were discharged in good health, and during the limited follow-up period, there has been no recurrence. We would like to emphasize that obturator hernia should be considered in the differential diagnosis when an elderly, thinly built woman presents with acute intestinal obstruction. Though the outcome of such cases depends on the clinical status and comorbidities of the patient, early diagnosis and treatment can help in reducing postoperative morbidity and mortality.

Estrangulated obturatory hernia. Case report of a challenging diagnosis of obstructive syndrome.

INTRODUCTION AND IMPORTANCE: Obturator hernia accounts for less than 1 % of all documented cases of pelvic hernias. It most commonly presents as an obstructive syndrome in elderly, multiparous, slim women, characterized by a wider pelvis that facilitates the passage of the hernia sac through the obturator foramen alongside the obturator nerve. In this case, adhering to the SCARE (Updating Consensus Surgical CAse REport) checklist criteria, we present a typical scenario involving an elderly woman who was initially misdiagnosed with a fecaloma, concealing an obturator hernia. CASE REPORT: An 85-year-old patient, displaying prodromal signs of senile disease, presented for medical attention with incapacitating abdominal pain in the right iliac fossa, accompanied by nausea and vomiting. Rectal examination revealed the presence of a fecaloma, and glycerin administration was performed rectally. The patient's condition worsened with the development of mental confusion and hyperactive delirium. Abdominal Computer tomography scan (CT scan) revealed right obturator hernia with enteral segment insinuation and dilation of the proximal bowel. An infraumbilical laparotomy was performed. The herniation of an ileal segment and the right ovary through the obturator foramen was identified. The content proved irreducible to manual maneuvers, leading to obturator muscle section following the dissection of the Retzius space. The right round ligament of the uterus was sectioned, and we manage to preserve the Obturatory branch of the lumbar plexus throughout dissection. A polypropylene mesh was positioned and secured with non-absorbable sutures on the Cooper's ligament, iliac crest, and obturator muscle and segmental enterectomy with primary anastomosis using a linear stapler was performed. CLINICAL DISCUSSION: This demanding case brings to the spotlight the importance of reevaluating even the usual cases. We provide our experience bringing together an unusual diagnosis after the conduction of a once diagnosed fecaloma that almost went down to a perforated acute abdomen. Hence the importance of suspect obturator hernia in unknown obstructive abdomen in elderly women. CONCLUSION: With this report we aim to raise awareness of careful propaedeutic inquiry of acute abdomen. We provide our experience bringing together the diagnosis that agrees with our literature review. Elderly patients commonly challenge the clinical evaluation, especially those with signs of senile disease. Thereby, inkling hidden diagnosis in typical scenarios can improve the patient's care in emergency settings.

Recurrent Obturator Hernia: A Rare Entity.

Obturator hernias are rare with an incidence of less than 1% of all hernias and are most common in frail, elderly females. They are difficult to diagnose and even more difficult to repair. They often present with a small bowel obstruction from the incarcerated bowel. We report a case of a recurrent obturator hernia after a laparoscopic repair using a patch of omentum. The recurrence was repaired laparoscopically with a trans-abdominal preperitoneal repair (TAPP) with mesh. Given the rarity of the disease, there is scarce literature on the ideal method of repair, especially in patients with recurrence. However, with recent trends toward minimally invasive preperitoneal mesh hernia repairs for inguinal and ventral hernias, this type of repair should be strongly considered for patients with obturator hernias as well.

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.

Incidentally found obturator hernias during totally extraperitoneal (TEP) inguinal hernia repair: a single-center experience.

PURPOSE: This study aimed to determine the occurrence of incidental obturator hernia and clinical risk factors of their appearance in patients undergoing totally extraperitoneal (TEP) inguinal hernioplasty. METHODS: Data were collected retrospectively from patients who underwent TEP inguinal hernioplasty between June 2020 and December 2022. RESULTS: A total of 251 patients were included in the study. Obturator hernias were found in 21 patients (8.4%). At admission, no patient presented clinical signs of an obturator hernia. There was a significant predominance of women in the obturator hernia compared to the non-obturator hernia group (28.6% vs. 10.9%, respectively, p=0.018). There was no correlation between age (p=0.479) and BMI (p=0.771) and the occurrence of obturator hernia. Additional obturator hernia repair within the TEP inguinal hernioplasty procedure did not influence the overall length of the surgery (60.86 minutes) compared to the standard TEP inguinal hernioplasty (61.09 minutes, p=0.876). CONCLUSIONS: The TEP inguinal hernioplasty allows the detection and repair of incidental obturator hernia. Through thorough inspection of the obturator canal, an asymptomatic obturator hernia can be detected and adequately treated within the same procedure, without the impact on the surgery duration, when performed by an experienced hernia surgeon.

Obturator Hernia in a Patient Undergoing Hemodialysis.

Obturator hernia is a rare condition that commonly affects frail older women. A 54-year-old woman presented to our hospital with left hip joint pain. She had suffered a left pubic bone fracture and commenced maintenance hemodialysis. Pelvic computed tomography (CT) showed an incarcerated small intestine through the left obturator foramen, while abdominal CT showed marked intestinal dilatation. She underwent emergency laparotomy, and the incarcerated small intestine was found to be necrotic. Partial small intestinal resection and bilateral obturator hernioplasty were performed. Because obturator hernia is a potentially fatal condition, early detection and treatment are important.

Intestinal obstruction, obturator hernia, and/or colonic neoplasms: a case study.

Occlusive hernias are rare and difficult to diagnose. We present an extraordinary case of simultaneous occurrence of an obturator hernia with colon cancer. An 86-year-old woman arrived at the hospital after ˃2 weeks of abdominal pain, nausea, vomiting, and constipation. The computed tomography axis map showed that part of the right lower abdominal small intestine had intruded into the femoral triangle through the obturator, which was diagnosed as an obturator hernia. When the abdominal cavity was opened for herniorrhaphy, a 4 × 4 cm colon mass was observed. Only herniorrhaphy was performed, without any complications. At present, there has been no report of the coexistence of occlusive hernia and colon cancer; the main symptoms are intestinal obstruction, nausea, vomiting, and constipation. The decision whether the tumor should be removed simultaneously with herniorrhaphy and/or a mesh patch.

Hernia obturatriz izquierda, obstrucción intestinal y hernia inguinal bilateral: Reporte de caso / Left obturator hernia, intestinal obstruction and bilateral inguinal hernia: a case report

RESUMEN La hernia obturatriz tiene una incidencia de menos del 1% de todas las hernias de la pared abdominal, se presentan predominantemente en mujeres de edad avanzada y se caracteriza por la protrusión de las vísceras intraabdominales hacia el agujero obturador. El diagnóstico preoperatorio suele ser difícil debido a la falta de manifestaciones externas obvias, síntomas y signos inespecíficos y falta de sospecha clínica. El retraso en el diagnóstico y en el tratamiento de esta afección generalmente conduce a una alta tasa de mortalidad. Reportamos el caso de una paciente con hernia obturatriz complicada y hernia inguinal bilateral, la cual fue resuelto por cirugía mínimamente invasiva, no hubo complicaciones en la evolución postoperatoria, siendo su estancia hospitalaria siete días.

SUMMARY Obturator hernia has an incidence of less than 1% of all abdominal wall hernias, it is predominantly observed in elder women and it is characterized by protrusion of intra-abdominal viscera into the shutter hole. The preoperative diagnosis is difficult due to the lack of external manifestations, nonspecific symptoms and lack of clinical suspicion. Delaying diagnosis and treatment is associated with high mortality. We report the case of a female patient with a complicated obturator hernia with concomitant bilateral inguinal hernias that underwent minimally invasive surgery with no complications and a seven day stay in hospital.

Obturator hernia: An uncommon cause of intestinal obstruction: A case report.

INTRODUCTION AND IMPORTANCE: An obturator hernia is a rare cause of bowel obstruction. Due to its narrow passage in the obturator canal, these are more susceptible to becoming incarcerated and subsequently strangulated. Due to its challenging detection, obturator hernia is often diagnosed late. CASE PRESENTATION: A 75-year-old thin-built female with COPD presented to the emergency room with symptoms of abdominal obstruction. Abdominal examination revealed distension, firmness, rigidity, and tenderness with no bowel sounds. An erect abdominal X-ray showed multiple air-fluid levels, indicating an acute abdomen due to intestinal obstruction. Emergency exploratory laparotomy revealed an obturator hernia with strangulated ileum and perforation, necessitating resection and double barrel ileostomy. Unfortunately, despite all medical interventions, the patient succumbed to hospital-acquired pneumonia following the surgery. DISCUSSION: Obturator hernia, known as 'the skinny old woman hernia,' is rarely externally visible or palpable, leading to frequent undiagnosed cases. It presents with bowel obstruction or perforation and carries the highest morbidity among abdominal hernias. Timely intervention is crucial to prevent complications like bowel strangulation. CONCLUSION: This case report highlights the challenges of diagnosing and managing obturator hernia, a rare condition with significant morbidity. Early detection through imaging or operative findings is crucial to prevent complications like bowel strangulation, especially in older women at higher risk.

Rare Hernias as Surgical Emergencies: A Case Series of Five Cases.

Hernia is one of the most common clinically diagnosed cases seen in day-to-day practice. But some of them might pose a challenge in diagnosing the condition and, thus, their further management. Some types of hernias are rare and mimic the common presentation of the acute abdomen, thus requiring extra caution to keep hernias as a differential diagnosis in the acute abdomen. In this series, we report five cases of rare hernias presented to a tertiary care center in northern India over the course of one year. Two cases of paraduodenal hernias (PHs), a right and left, respectively, a male femoral hernia, an Amayand hernia, and an obturator hernia presented as acute abdomen in the emergency department, with challenges in their diagnosis, intraoperative findings, and their outcomes. Computed tomography is a useful diagnostic tool for arriving at the diagnosis pre-operatively in these situations.

Management and outcomes of obturator hernias: a systematic review and meta-analysis.

PURPOSE: Obturator Hernia (OH) is a rare type of abdominal wall hernia. It usually occurs in elderly women with late symptomatic presentation, increasing mortality rates. Surgery is the standard of care for OH, and laparotomy with simple suture closure of the defect is commonly used. Given the rarity of this disease, large studies are lacking, and data to drive management are still limited. This systematic review and meta-analysis aimed to describe current surgical options for OHs, with a focus on comparing the effectiveness and safety of mesh use with primary repair. METHODS: PubMed, EMBASE, and Cochrane were searched for studies comparing mesh and non-mesh repair for OH. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. RESULTS: One thousand seven hundred and sixty studies were screened and sixty-seven were thoroughly reviewed. We included 13 observational studies with 351 patients surgically treated for OH with mesh or non-mesh repair. One hundred and twenty (34.2%) patients underwent mesh repair and two hundred and thirty-one (65.81%) underwent non-mesh repair. A total of 145 (41.3%) underwent bowel resection, with the majority having a non-mesh repair performed. Hernia recurrence was significantly higher in patients who underwent hernia repair without mesh (RR 0.31; 95% CI 0.11-0.94; p = 0.04). There were no differences in mortality (RR 0.64; 95% CI 0.25-1.62; p = 0.34; I2 = 0%) or complication rates (RR 0.59; 95% CI 0.28-1.25; p = 0.17; I2 = 50%) between both groups. CONCLUSION: Mesh repair in OH was associated with lower recurrence rates without an increase in postoperative complications. While mesh in clean cases is more likely to offer benefits, an overall recommendation regarding its use in OH repair cannot be made due to potential bias across studies. Given that many OH patients are frail and present emergently, the decision to use mesh is complex and should consider the patient's clinical status, comorbidities, and degree of intraoperative contamination.

Case report: Obturator hernia: Diagnosis and surgical treatment.

Background: Obturator hernia (OH) is a rare external abdominal hernia, accounting for only 0.07%-1% of all hernia cases. Because the female pelvis is wider and there is less preperitoneal adipose tissue, the obturator canal is larger, which can lead to herniation of abdominal contents when abdominal pressure increases in elderly women with thin body. The clinical symptoms of patients with obturator hernia included abdominal pain, nausea, vomiting, etc., and the mass in the inguinal region could not be touched. The positive Howship-Romberg sign is a specific sign of OH. CT is the first choice for the diagnosis of obturator hernia. Since intestinal incarceration in OH patients is prone to lead to intestinal necrosis, emergency surgical treatment is often required. However, due to the lack of specificity of its clinical manifestations, the misdiagnosis rate is high, which often leads to the delay of diagnosis and treatment. Methods: We report the case of an 86-year-old woman with a thin body and a history of multiple deliveries. The patient presented with abdominal pain, bloating, and constipation for 5 days. Physical examination revealed a positive Howship-Romberg sign on the right side, and CT examination suggested intestinal obstruction. Therefore, an urgent exploratory laparotomy was performed. Results: After opening the abdominal cavity we found that the wall of the ileum was embedded in the right obturator, and the proximal bowel was significantly dilated. We restored the embedded bowel wall to its original position, resected the necrotic bowel and performed an end-to-end anastomosis of the small intestine. The right hernia orifice was sutured, and OH was diagnosed during the operation. Conclusion: This article summarizes the diagnosis and treatment of OH by sharing this case, so as to provide a more detailed plan for early diagnosis and treatment of OH.

A rare case of left-sided obturator hernia diagnosed by computed tomography.

Obturator hernia is a rare condition that is difficult to detect clinically. We highlight the importance of a CT scan in establishing an early diagnosis of an obturator hernia, effective surgical intervention planning, thereby enhancing the result.