CASE REPORT
AN OBTURATOR HERNIA: DIFFICULT
DIAGNOSIS-EASY REPAIR
Poonam Tanwar∗ , Amit Jaiswal∗ , Pritviraj S K∗ , Jaikaran Ruhil∗∗ and Rajesh Godara∗∗,1
∗ Department
of Radiodiagnosis, PGIMS Rohtak, Haryana. India., ∗∗ Department of Surgery, PGIMS Rohtak, Haryana. India
ABSTRACT
Obturator a hernia is a rare type of a pelvic hernia which is hard to diagnose clinically because of non-specific symptoms
and obscure physical findings. Delayed diagnosis, associated comorbidities and frequent complications lead to significant
mortality. Use of computerised tomography in the early diagnosis and timely repair - either suture-based or mesh
placement depending on circumstances is associated with good outcome.
KEYWORDS: computed tomography, obturator hernia, intestinal obstruction
Introduction
An obturator hernia usually occurs in elderly, thin and multiparous women.This entity is relatively rare and poses a diagnostic challenge. An obturator hernia is one of the significant causes
of intestinal obstruction, especially in emaciated elderly women
with chronic disease. A palpable groin mass typical of abdominal wall hernias is not common in these patients because hernia
mass is concealed beneath the pectineus muscle. The causes of
high mortality are delayed recognition, resultant perforation of
the gangrenous bowel, peritonitis and high incidence of concurrent medical illness in this group of patients. Rapid evaluation
of CT scan and surgical intervention reduces the morbidity and
mortality from an obturator hernia.
Case reports
A 62-year-old multiparous lady, known the case of hypertension, was admitted to surgical emergency room with complaints
of gradually progressive colicky pain in the abdomen, nausea,
vomiting and constipation for last four days. Clinical history
Copyright © 2016 by the Bulgarian Association of Young Surgeons
DOI:10.5455/ijsm.obturatorhernia
First Received: March 04, 2016
Accepted: March 19, 2016
Manuscript Associate Editor: George Baitchev (BG)
Editor-in Chief: Ivan Inkov (BG)
Reviewers: Mora Laura (ES); Paulina Vladova (BG); Ashraf Hefny (AE)
1
Rajesh Godara, Department of Surgery, PGIMS Rohtak, Haryana, India,
[email protected]
revealed three similar episodes of abdominal complaints in last
one year that either resolved spontaneously or with the help of
analgesic medications. She also complained of intermittent left
hip pain with radiation to the medial aspect of the thigh lasting
for several months.
At the time of admission she was in shock with a tachycardia of 110/min, blood pressure 88/40 mmHg, respiratory rate
20/min, pallor and a fever of 37.8 C. Per abdominal examination
revealed distended, tender abdomen with guarding and absent
bowel sounds on auscultation. Per rectal and vaginal examinations were within normal limit. Vigorous resuscitation was
commenced, correcting an anaemia (Hb 6 g/dl) with three units
of whole blood, and broad spectrum antibiotics covering aerobes
and anaerobes were infused. The plain abdominal radiograph
revealed multiple distended small bowel loops with air fluid levels compatible with small bowel obstruction. Contrast-enhanced
computed tomographic examination revealed free fluid and air
specks in the peritoneal cavity, multiple dilated small bowel
loops were noted down to left side of the pelvis. A transition
point with a collapsed and thickened small bowel loop with
surrounding fluid in the hernia sac was noted caught between
left pectineus and obturator extends muscle [Figure1-3 arrow].
A presumptive diagnosis of strangulated obturator hernia with
perforation was made. An urgent exploratory laparotomy was
done which revealed a loop of mid ileum herniated in left obturator canal with extensive segment necrosis of ileum and multiple
small perforations. The patient underwent resection and primary anastomosis of bowel with suture repair of an obturator
hernia. The postoperative period was uneventful.
Poonam Tanwar et al./ International Journal of Surgery and Medicine (ARTICLE IN PRESS)
Figure 1: CECT pelvis showing collapsed thick walled small
bowel loop[arrow] in left obturator canal anterior to left obturator muscle.
Figure 2: CECT of pelvis showing fluid-filled hernia sac[arrow]
herniated in between the pectineus muscle anteriorly and obturator muscle posteriorly.
Figure 3: CECT Axial section of the abdomen showing multiple
dilated small bowel loops showing air-fluid levels with collapsed
large bowel at the periphery.
Discussion
This unusual abdominal wall hernia occurs through obturator foramen in the pelvis with no visible palpable lump. The
incidence rates vary widely throughout world accounting for
0.07%–1.0% of all hernias, and responsible for 0.2%–1.6% of all
small bowel mechanical obstruction cases[1]. Incidence among
Asians has been shown to be high compared to Westerns[2].
Due to non-specific signs and symptomatology obturator hernia poses a diagnostic challenge thus making a preoperative
diagnosis difficult. Usual delay in management and associated
comorbidities in this age group account for highest mortality
among all abdominal wall hernias (range 13%–40%)[1]. An obturator hernia, occurs through a 2–3 cm long and 1 cm wide
obturator canal which frequently contains obturator nerve and
vessels. This hernia was first described by Arnaud de Ronsil in
1724 and successfully repaired by Henry Obre in 1851[3]. An
obturator hernia is nine times more common in females due
to their wider pelvis, triangular obturator canal opening and
greater transverse diameter. This effects most frequently emaciated patients aged between 70 and 90 years, hence its nickname,
“little old lady’s hernia”(4). The loss of protective preperitoneal
fat and lymphatic tissue around obturator vessels and nerves
facilitates the formation of a hernia. Clinical presentation of
an obturator hernia is vague with symptoms of intestinal obstruction present in more than 80% of patients. Obstruction is
usually partial, intermittent due to a high frequency (41%–100%)
of Richter’s type herniation into obturator canal and this finding is an important clue to diagnosis. Howship-Romberg sign
characterised by pain in the medial thigh is present in 15%–50%
of cases. Hannington-Kiff sign that refers to an absent adductor
reflex in the thigh if presently is more accurate for an obturator
hernia. These clinical signs are due to compression of the obturator nerve by the hernia sac and its contents. Digital rectal and
vaginal examination can sometimes reveal a palpable mass and
Poonam Tanwar et al./ International Journal of Surgery and Medicine (ARTICLE IN PRESS)
helps in diagnosis of an obturator hernia. Imaging modalities
described to diagnose an obturator hernia include plain radiographs of abdomen, ultrasonography, barium enema and most
precise computerized tomography(CT) of abdomen and pelvis.
Recent series have reported definite, early diagnosis of obturator hernia in 100% of cases with minimally invasive, readily
available CT scan[5]. There is often hesitation to operate early
because of vague symptoms, delayed presentation, advanced
age, the presence of comorbidities and debilitating conditions.
Despite its rarity, a variety of operative approaches have been described to repair an obturator hernia i.e., abdominal, retropubic,
obturator, inguinal and more recently, the laparoscopic approach.
Techniques to handle hernia defect include simple closure with
interrupted sutures and synthetic mesh. There is a voluminous
surgical history of use of various things like costal cartilage,
pectineus muscle, rolled-up tantalum gauze, osteoperiosteal flap
from the pubic bone, free omentum and uterine fundus or round
ligament, etc. Whatever approach selected emphasis should be
on timely evaluation, resuscitation and intervention to reduce
the morbidity and mortality.
Conclusion
An obturator hernia, a rare entity, usually afflicts elderly, emaciated female patients. Clinical signs are nonspecific and seldom
thought of. Early diagnosis with a CT scan and timely surgery
is crucial to prevent morbidity and mortality. The laparoscopic
approach has been described to assist in diagnosis, reduction
and repair obturator hernia in selected cases.
Authors’ Statements
Competing Interests
The authors declare no conflict of interest.
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Poonam Tanwar et al./ International Journal of Surgery and Medicine (ARTICLE IN PRESS)