Obturator hernia

Retrospective comparison of laparoscopic and open surgery for obturator hernia: a single-center experience

PURPOSE

This retrospective cohort study aims to compare perioperative outcomes between laparoscopic and open surgical repair of obturator hernia, a rare but clinically significant abdominal wall hernia.

METHODS

We analyzed 13 consecutive patients with CT-confirmed obturator hernia causing small bowel obstruction (2017-2023). Six underwent open repair and seven received laparoscopic transabdominal preperitoneal (TAPP) repair with mesh. Outcomes included operative time, blood loss, hospitalization duration, and CRP levels.

RESULTS

Laparoscopic repair significantly reduced hospitalization duration (median 7 vs. 13 days; P = 0.049) and postoperative inflammation (CRP 10.66 vs. 79.07 mg/L; P = 0.003), with less blood loss (10 vs. 30 mL; P = 0.001). No recurrences occurred during 12-month follow-up.

CONCLUSIONS

Laparoscopic obturator hernia repair demonstrates advantages in reducing hospital stay, minimizing surgical trauma, and attenuating systemic inflammatory response as compared to open approach. However, larger multicenter studies are warranted to validate these findings given the limited sample size.

Small bowel obstruction secondary to strangulated obturator hernia with transected ileal segment: A case report

INTRODUCTION AND IMPORTANCE

Obturator hernia is a rare abdominal wall hernia (<1 % incidence) that occurs through the obturator foramen, often in elderly, emaciated women. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis is the diagnostic modality of choice, with a high accuracy of 78 %-100 %.

CASE PRESENTATION

An 84-year-old frail woman with COPD presented with generalized abdominal pain, abdominal distention, vomiting, and right thigh pain. CECT revealed a right-sided obturator hernia causing small bowel obstruction. Emergency exploratory laparotomy revealed a right-sided strangulated obturator hernia. Postoperatively, the patient developed septic shock and multiorgan dysfunction syndrome (MODS) and succumbed to death on the 5th postoperative day.

CLINICAL DISCUSSION

Obturator hernia is a rare abdominal hernia with an incidence of 0.07-1 %, an often-overlooked condition, more common in elderly women (around 70-90 years) with risk factors like low BMI, multiparity, and chronic conditions such as COPD. It presents with nonspecific symptoms, including abdominal pain, distension, and vomiting, and is often difficult to diagnose. Early CECT has improved the preoperative diagnosis rate from 43 % to 90 %, thus playing a crucial role in preventing morbidity and mortality. Treatment is surgical, but the mortality rate is high due to delayed diagnosis, bowel strangulation, and underlying preexisting illness.

CONCLUSION

Obturator hernias are a rare but important cause of small bowel obstruction, especially in elderly, frail, malnourished women without prior abdominal surgeries. Medial thigh pain and mild abdominal distension warrant high suspicion and prompt diagnosis using CECT. Early surgical intervention is critical to prevent severe complications and reduce associated morbidity and mortality.

A Case of Laparoscopic Transabdominal Pre-peritoneal Hernia Repair Using a 3D Mesh Inversion Technique for Bilateral Obturator and Femoral Hernias After Incarcerated Obturator Hernia Reduction

An obturator hernia (OH) is a rare type of hernia that accounts for a very small proportion of all hernias and cases of small bowel obstruction. This condition predominantly affects older, underweight individuals, with the vast majority of patients being women. Laparotomy with simple suture closure of the defect is commonly used as surgical treatment for OH. However, the closeness of the obturator nerve to the obturator defect causes difficulty in observing this nerve due to the deep operative field in laparotomy. Thus, transabdominal pre-peritoneal hernia repair (TAPP) has advantages over an open approach, and TAPP is now commonly performed for OH. In the case described here, an 86-year-old female patient presented with lower abdominal pain and vomiting. Abdominal computed tomography revealed a right-sided OH causing intestinal obstruction, and the patient was referred to our hospital. Her medical history included hypertension, dementia, and an artificial head replacement for a left femoral neck fracture. Laboratory tests showed elevated white blood cell (WBC) of 13,700/μL, but other results were normal. Manual reduction of the hernia was successful, leading to symptom improvement, and the patient was admitted for observation. She was discharged on day three after admission. After one month, laparoscopic TAPP was performed. Bilateral OHs and femoral hernias were observed. Using a recently proposed 3D mesh inversion technique, the mesh was fitted anatomically for the OH. This is the first reported case of elective TAPP using a 3D MAXTM Light Mesh (Bard, Warwick, RI, US) with an inversion technique for bilateral OH and femoral hernia after incarcerated OH reduction.

Leg Pain-An Unexpected Twist

BACKGROUND

Obturator hernia is a rare condition, often presenting with non-specific symptoms, such as thigh pain, groin pain, nausea, or vomiting. Obturator hernias are most common in thin, elderly women. Oftentimes, they are diagnosed late in the disease course resulting in complications and high morbidity and mortality.

CASE REPORT

We present the case of a 75-year-old female who presented with right thigh pain with no other symptoms. After computed tomography (CT) of the abdomen/pelvis, the patient was found to have an incarcerated obturator hernia complicated by a small bowel obstruction, ultimately requiring urgent surgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the very general symptoms associated with the condition, the diagnosis of obturator hernia can easily be missed, leading to a delayed diagnosis, more complications, and a higher morbidity and mortality rate. Due to the risk associated with a delayed diagnosis, it is important for emergency physicians to maintain a high clinical suspicion for the diagnosis.

Obturator hernia (the little old lady's hernia) diagnosed via computed tomography: a case report

Obturator hernia is an infrequent clinical entity of abdominal wall hernia, accounting for an incidence rate ranging from 0.073 to 2.2% of all hernias and being responsible for 0.2-1.6% of all cases of mechanical intestinal obstruction. The computed tomography (CT) scan, as an imaging modality, is critical in improving the diagnostic rate of obturator hernia.

Case presentation

The authors herein report an 87-year-old thin male patient with a known history of chronic obstructive pulmonary disease who presenting with complaints of abdominal pain for 3 days and constipation for 2 days, as well as one episode of vomiting without any features of peritoneal irritation, which was diagnosed early as a right-sided obturator hernia via CT and managed with exploratory laparotomy with hernia reduction and polypropylene mesh repair.

Discussion

Obturator hernia is a rare surgical phenomenon with a varied clinical spectrum, ranging from asymptomatic to presenting as intestinal obstruction. The CT scan plays a critical role in the detection of obturator hernias, which ameliorates the possible significant postoperative morbidity and mortality.

Conclusion

This report demonstrates that a high index of suspicion combined with CT imaging aids in early diagnosis and management, thus overcoming the reluctant morbidity.

Laparoscopic management of obturator hernia in the setting of intestinal obstruction: A report of two cases and review of literature

Owing to its rarity and non-specific clinical features, a diagnosis of obturator hernia is often delayed until the patient presents with intestinal obstruction. Often the diagnosis is made on a Computed Tomography (CT) scan or during exploratory laparotomy. While a laparoscopic approach is well described in an elective scenario, open surgery through a midline laparotomy has been the preferred approach for obturator hernia with intestinal obstruction. However, a few cases of obstructed obturator hernia have been reported that have been managed laparoscopically. We present our experience of two elderly patients who presented with intestinal obstruction. A CT scan helped clinch the diagnosis of obturator hernia as the cause and both were managed laparoscopically.

Rare case of obturator hernia: Surgical anatomy, planning, and considerations

Obturator hernia is a rare variation of abdominal hernias that cause significant morbidity and mortality, especially in the elderly population. Incidence rates vary but account for approximately 0.07%–1.0% of all hernias. Literature on laparoscopic versus laparotomy, as well as types of closure (primary vs mesh) have not been well described in the literature. Obturator hernias, although rare, require a high index of suspicion and care in surgical management as many of these patients will be elderly with a multitude of comorbid conditions. Further research and reporting on technique and type of closures utilized when these rare hernias are encountered by surgeons would benefit the surgical community on practices and management of obturator hernias. Here, we present a case of an elderly female who presented with complaints of obstructive symptoms and abdominal pain secondary to an obturator hernia.

Prediction of bowel obstruction caused by obturator hernia using risk factor categories on clinical characteristics and multidetector computed tomographic findings

PURPOSE

To detect risk factors on clinical characteristics and multidetector computed tomographic (MDCT) findings for predicting bowel obstruction in patients with obturator hernia.

METHODS

We retrospectively reviewed 47 patients who had an obturator hernia diagnosed by MDCT and/or surgery. The patients were divided into obstruction and non-obstruction group based on the presence or absence of bowel obstruction on MDCT images. Uni- and multivariate analyses were performed to identify risk factors for predicting bowel obstruction.

RESULTS

There were 26 patients (55.32%) in the obstruction group and 21 patients (44.68%) in the non-obstruction group. Patients in the obstruction group were older (P = 0.002) and had more women (P = 0.033) and lower body mass index (BMI) (P = 0.0001) than patients in the non-obstruction group. The non-obstruction group suffered fewer bowel obstruction symptoms (P = 0.0001), Howship-Romberg (HR) sign (P = 0.012), deaths (P = 0.008) and major postoperative complications (P = 0.047). The hernia sac in the obstruction group had greater mean major diameter (P = 0.0001) and volume (P = 0.001) than those in the non-obstruction group. Multivariate analysis showed that age [odds ratio (OR) 1.18, 95% confidence interval (CI) 1.00-1.39, P = 0.046] and major diameter of hernia sac (OR 68.17, 95% CI 4.52-1027.70, P = 0.002) were independent risk factors associated with bowel obstruction in patients with obturator hernia.

CONCLUSIONS

Patient's age and major diameter of hernia sac are independent risk factors resulting in bowel obstruction in patients with obturator hernia. Obturator hernia repair before bowel obstruction development may result in better outcomes and fewer postoperative complications.

Strangulated obturator hernia: Report of two cases

Obturator hernia is a rare condition, which can be life-threatening if misdiagnosed. We must consider the diagnosis in case of a bowel obstruction especially in elderly women.

Fascinating history of groin hernias: Comprehensive recognition of anatomy, classic considerations for herniorrhaphy, and current controversies in hernioplasty

Groin hernias include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias. Here, we summarize historical turning points, anatomical recognition and surgical repairs. Groin hernias have a fascinating history in the fields of anatomy and surgery. The concept of tension-free repair is generally accepted among clinicians. Surgical repair with mesh is categorized as hernioplasty, while classic repair without mesh is considered herniorrhaphy. Although various surgical approaches have been developed, the surgical technique should be carefully chosen for each patient. Regarding as interesting history, crucial anatomy and important surgeries in the field of groin hernia, we here summarized them in detail, respectively. Points of debate are also reviewed; important points are shown using illustrations and schemas. We hope this systematic review is surgical guide for general surgeons including residents. Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.

A decade review of emergency obturator hernia repairs

BACKGROUND

Obturator hernia is a rare pelvic hernia associated with a high morbidity and mortality. It most commonly occurs in elderly, multiparous females with symptoms and signs of small bowel obstruction. We present an Australian hospital network experience on emergency presentations of obturator hernias highlighting differences between clinical profile and surgical management.

METHODS

A retrospective review of adult patients diagnosed with acute obturator hernia during a 10 year period (2010-2020) was conducted across 10 major Sydney hospitals in New South Wales, Australia.

RESULTS

Obturator hernia was diagnosed in 18 patients (mean 82.7 years, range: 60-96 years old), all confirmed on pre-operative computed tomography imaging. The most common presentations were elderly women demonstrating clinical features of a small bowel obstruction. The mean onset of symptoms from home to hospital admission was 49.4 h. Non-survivors had a significantly elevated urea level (15.6 vs. 7.8 mmol/L, p = 0.036) at presentation and a longer delay from onset of presenting symptoms to diagnosis (84.0 vs. 36.2 h, p = 0.028). Eleven patients underwent urgent laparotomy and six laparoscopic repairs. The mean operative time was 101.0 min. The average hospital length of stay was 16.2 days with a mortality rate of 27.8%.

CONCLUSION

Timely diagnosis and operative intervention for obturator hernia is the cornerstone of management.

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.

Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of "tension-free repair" is generally accepted, and surgical repairs with mesh are categorized as "hernioplasties". Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal (TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal (posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.

Emergency laparoscopic repair of an incarcerated obturator hernia, a case report

•

Obturator hernias have high morbidity and mortality which require emergency treatment.

•

These hernias are usually treated via open surgery despite the advancement of laparoscopic surgery.

•

We describe and demonstrate a repair method via minimally invasive surgery.

•

Laparoscopic repair is feasible in the emergency setting.

Obturator hernias are rare hernias with high morbidity and mortality if not diagnosed and treated promptly. Various minimally invasive techniques have been reported in literature. Here we describe a novel technique of repairing an obturator hernia complicated by small bowel incarceration and obstruction, via a laparoscopic trans-abdominal approach.

Laparoscopic assisted repair of strangulated obturator hernia-Way to go

INTRODUCTION

Obturator hernias are a rare subtype of intra-abdominal hernias that present with considerable challenges in both diagnosis and surgical repair. Delays in diagnosis and management significantly increases the Morbidity and Mortality.

PRESENTATION OF CASE

An elderly 70-year-old female presented with Lower abdominal pain radiating to the medial side of the left leg over a year that has become persistent and continuous over the 3 day period. Patient was found to have a Richter's type of strangulated obturator hernia on diagnostic laparoscopy. A laparoscopic assisted resection of the strangulated small bowel and repair of the Hernia was performed. Postoperatively patient had an uneventful recovery.

DISCUSSION

Surgical treatment is the standard of care for an obturator Hernia. Increasing number of laparoscopic repairs are being performed in the recent past. Minilaparotomy greatly facilitates the resection and anastomosis of a dead bowel without jeopardizing cosmesis and mesh placement at the time of repair.

CONCLUSION

Heightened awareness of the condition combined with our proposition of a Hybrid repair achieves optimal results in an emergency setting. A Laparoscopic assisted repair of a strangulated hernia provides a durable repair and at the same time offers the patient benefits of minimally invasive surgery.

Case report: Laparoscopic totally extraperitoneal repair of an obturator hernia with self-gripping mesh under spinal anaesthesia

•

Laparoscopic repair of obturator hernia with self-gripping mesh can adopted to reduce the morbidity of open repairs.

•

It is safe to perform laparoscopic TEP repairs under spinal anesthesia.

Introduction

Obturator hernias account for less than 0.073% of all hernias and less than 1.6% of all cases of mechanical bowel obstructions.

Presentation of Case

We present a case of a 79 year-old elderly female with two recurrent bowel obstructions that have resolved with conservative management. On the third presentation we performed a totally extraperitoneal repair (TEP) with conscious sedation and a L3/4 spinal block. An obturator defect was patched with a self gripping mesh (progrip). The patient was discharged day 2 post operatively.

Discussion

Laparoscopic surgery can be safely performed in high risk patients with careful monitoring. Laparoscopic surgery is usually associated with a shorter post-operative length of stay.

Conclusion

This case demonstrates the successful but unconventional repair of an obturator hernia in a patient who had a high risk of significant morbidity and mortality with a more conventional anaesthesia and surgery.

Laparoscopic Mesh Repair of Bilateral Obturator Hernias Post-Peritoneal Dialysis

Abdominal wall hernias are prevalent in patients undergoing peritoneal dialysis (PD). Obturator hernias, first described by Arnaud de Ronsil in 1724, are an uncommon type of hernia where intra-abdominal contents protrude through the obturator foramen. The following case highlights a rare presentation of bilateral obturator hernias with right femoral and inguinal hernia in an 82-year-old woman post-PD. This patient presented with 5 months of bilateral thigh pain and swelling and was found to only have a right-sided obturator hernia on computer tomography (CT) scan. Intraoperatively, bilateral obturator hernias were found along with right inguinal and femoral hernias, which were all repaired laparoscopically with polypropylene mesh. Postoperatively, the patient developed a self-limiting port site hematoma and resumed PD 1 month post-surgery. Due to the high morbidity and mortality from obturator hernias, prompt diagnosis and treatment are imperative. Compared with open hernia repair, laparoscopic hernia repairs are associated with quicker return to usual activities and less persisting pain and numbness. This case portrays that laparoscopic approach to bilateral obturator hernias can be considered in patients post-PD.

Impact of bowel resection on postoperative mortality in patients with obturator hernias

PURPOSE

The purpose of this study was to identify any potential correlation between postoperative mortality and bowel resection in patients with obturator hernias.

METHODS

In total, 21 patients who underwent emergency surgery for a primary incarcerated obturator hernia during a 9-year period were retrospectively assessed regarding the correlation between postoperative mortality within 30 days from surgery and bowel resection.

RESULTS

The 21 hernias occurred in 20 women and 1 man. The mean age at presentation was 83.3 years. Eight hernias required bowel resection, and operations using mesh were performed for eight hernias. Complications occurred in association with nine hernias, and three patients died. Postoperative mortality was correlated with complications (p = 0.016) and bowel resection (p = 0.010). Patients undergoing bowel resection had a significantly longer operation time (p = 0.009) and a higher rate of postoperative complications (p = 0.018). The systolic blood pressure, pH, and base excess were significantly lower in patients who did than did not undergo bowel resection (p = 0.017, 0.009, and 0.015, respectively).

CONCLUSION

As the aging population continues to expand, the number of patients with obturator hernias is speculated to increase. Elderly people with comorbidities require immediate operative procedures because their general condition tends to be exacerbated by bowel obstruction. Postoperative management may be carefully performed in patients with bowel resection because the postoperative mortality rates may be higher in these patients.

A rare presentation of small bowel obstruction

A 92-year-old, 41 kg female presented with a 4-day history of abdominal distension, intermittent lower abdominal pain, nausea, vomiting and lack of bowel opening. Contrast-enhanced CT scan of the abdomen and pelvis showed multiple dilated small bowel loops, secondary to incarceration of the ileum in an obturator hernia (OH) on the right. The patient underwent an emergency laparotomy with reduction of the OH. The small bowel was viable and no resection was required. OH is a rare but significant cause of small bowel obstruction, with a high mortality rate. Of all the imaging modalities reviewed, CT scan is highly effective in reducing diagnostic delay, and ultimately can reduce morbidity and mortality rates of patients presenting with an incarcerated OH.

[Case report: Occlusion and intestinal necrosis by obturator hernia]

BACKGROUND

Obturator hernia is a rare variety of abdominal hernia, it accounts for 0.07%-1.0% of all hernias, and occurs most often in women of advanced age and multiparous.

CLINICAL CASE

A 78-year-old female was admitted to the Emergency Department due to nausea, vomiting, complaints of abdominal discomfort and obstipation for the last 7 days. Abdominal CT scan showed dilated small bowel loops and multiple air-fluid levels near to a small bowel loop obturator hernia, between external obturator and pectineus muscle. Emergency laparotomy was performed and during the surgery, loop of small intestine was revealed herniated into the obturator foramen, 130cm from the angle of Treitz. Necrosis of small intestine was found, without perforation. Resection of the 10cm affected jejunal segment was performed and a side-to-side bowel anastomosis was fashioned. Also simple suture closure of obturator foramen was performed.

CONCLUSION

Obturator hernia is relatively rare. However physicians should keep it in mind and have clinical suspicion for obturator hernia as a cause of intestinal obstruction in female, elderly and multiparous patients in order to make an appropriate diagnosis and avoid bowel ischaemia.

Laparoscopic total extraperitoneal repair of preoperatively diagnosed bilateral obturator and incidental bilateral femoral herniae

Obturator hernia (OH), a rare type of hernia, is associated with high morbidity and mortality. Diagnosis is often delayed as clinical symptoms are typically non-specific. OH is frequently associated with other occult inguinopelvic herniae. Early diagnosis is vital to decrease morbidity and mortality. We report the case of a 75-year-old woman who presented to the surgical outpatients' department with non-specific bilateral groin pain radiating to the thighs. CT of the pelvis demonstrated bilateral OH with no radiological evidence of bowel obstruction. Semiurgent elective laparoscopic total extraperitoneal mesh repair was performed. Intraoperative findings confirmed bilateral obturator herniae as well as incidental bilateral femoral herniae. This case highlights the need for a high index of suspicion for such concomitant hernias that, in the presence of OH, may only be identified intraoperatively.

Laparoscopic Views of Obturator Hernia

In this report, we highlighted the clinical manifestations of obturator hernia and focused on laparoscopic views. Given its rarity and vague symptoms, the early diagnosis of obturator hernia presents a challenge. Although delays in diagnosis cause high rates of morbidity and mortality, CT with multi-planar reformations provides an excellent means of preoperative diagnosis. Despite current progress of laparoscopic surgery, its indication is believed to be limited only in elective obturator hernia repairs because of technical difficulties associated with bowel strangulation followed by a resection anastomosis. However, in selected cases, laparoscopic techniques can provide a minimally invasive option for obturator hernia repairs. These laparoscopic views, together with CT imaging, allow a better understanding of spatial anatomy and abnormality surrounding an obturator hernia.

Acute appendicitis within an obturator hernia

We present the case of a 17-year-old girl who presented with the signs and symptoms of acute appendicitis; however, during laparoscopic surgery, it was found that the appendix had herniated through the obturator canal. This pathology has previously been associated with an unfavourable outcome and has been reported, in the literature, in older, emaciated women.

'Little old lady's hernia' causing small bowel obstruction in a man: a case report with a review of literature on the pathophysiology of obturator hernias

Commonly known as 'little old lady's hernia', obturator hernias are usually seen in frail, octogenarian multiparous women reporting non-specific nausea and vomiting, abdominal pain and anteromedial thigh pain. They are exceedingly rare; even less frequently are they diagnosed preoperatively, with the vast majority being found incidentally at laparotomy for small bowel obstruction. This case report describes an atypical presentation of a 'little old lady's hernia' in a man, in whom, thanks to high degree of clinical suspicion, an incarcerated obturator hernia was diagnosed preoperatively and treated successfully.

Small bowel obstruction secondary to bilateral obturator hernia: a rare occurrence

Obturator hernia (OH) is a rare type of pelvic hernia. It can cause significant morbidity and mortality, especially in the elderly age group. Delayed treatment is associated with high rates of strangulation (25-100%). We present an 88-year-old woman who presented with symptoms of bowel obstruction and right hip pain. Computed tomography (CT) abdomen revealed bilateral OHs and bowel obstruction secondary to the right OH. She was managed conservatively due to her age and co-morbidities and her bowel obstruction subsequently resolved. She was discharged, only to re-present 1 month later with similar complaints. A repeat CT scan revealed bilateral OHs and bowel obstruction due to the left OH. She underwent midline laparatomy and both OHs were reduced. The right OH was fixed with polypropylene mesh plug and the left OH was fixed with primary closure. The patient recovered and no recurrence was noted during follow-up.

Surgical morbidity and mortality in obturator hernia: a 10-year retrospective risk factor evaluation

Obturator hernia is a rare condition occurring predominantly in elderly, thin, female patients and causes significant morbidity and mortality. Due to obscure presenting symptoms and signs, diagnosis and management are often delayed. While previous studies have attributed the high mortality to the delay in diagnosis, current literature remains controversial about this issue. The aim of this study was to identify peri-operative risk factors associated with mortality in patients with obturator hernia at our hospital.

METHODS

We retrospectively reviewed our series of 20 consecutive patients who underwent surgical repair of 21 obturator herniae and examined their clinical characteristics and post-operative outcomes.

RESULTS

Overall mortality rate was 47.6 %. Survivors did not differ from non-survivors in terms of basic demographics and operative parameters (operative time, blood loss and the need for intestinal resection). The use of computed tomography for pre-operative diagnosis was associated with reduced need for bowel resection, but did not result in shorter time to operation or improved morbidity and mortality. Our series demonstrated that early timing of surgery alone did not improve operative outcome. The absence of bowel motion and a high serum urea level at the time of operation were independent factors for mortality.

CONCLUSIONS

Obturator hernia remains a highly lethal surgical emergency. Adequate peri-operative resuscitation may be the key to further improvement in surgical outcomes.

Obturator hernias: A review of the laparoscopic approach

BACKGROUND:

Obturator hernias (OH) account for a rare presentation to the surgical unit usually associated with bowel obstruction and strangulation. The treatment of this condition is classical laparotomy with repair of the hernia and bowel resection, if deemed necessary; recently, the laparoscopic approach has been reported in literature. This review examines the existing evidence of the safety and effectiveness of the laparoscopic approach for the management of OH.

MATERIALS AND METHODS:

We have conducted a systematic review of the cases reported in the literature between 1991 and 2009, using Medline with PubMed as the search engine, as well as Ovid, Embase, Cochrane Collaboration and Google Scholar databases to identify articles in English language reporting on laparoscopic management for the treatment of this condition.

RESULTS:

A total of 17 articles reporting on 28 cases were found. We describe the pooled data for demographics, operative time, hospital stay, morbidities and method of repair. We also compare to the results of the laparoscopic repair of other types of hernias in the literature.

CONCLUSION:

This approach was found to be a safe and effective approach for the repair of OH as compared to the classical open approach; however, its adoption as the gold standard needs further multicenter trials.

Fifteen-year experience in managing obturator hernia: from open to laparoscopic approach

PURPOSE

Obturator hernia is a rare disease and preoperative diagnosis is always difficult. There are increasing reports employing laparoscopic approach in the recent literature. Our aim was to review and compare the open and laparoscopic approach in repairing obturator hernia.

METHODS

All patients with obturator hernia from 1997 to 2011 were recruited. Patient's demographics, presentation, operative details, morbidity, and mortality were retrospectively collected and reviewed.

RESULTS

There were 36 patients during the 15-year period. All of them were elderly ladies (median 83). Nineteen underwent open surgery while 16 received laparoscopic surgery. Both age and ASA were comparable. The median operative time was 68 and 65 min for laparoscopic and open group, respectively (p = 0.690). The median hospital stay was significantly longer in the open group (19 vs 5 days, p = 0.007). There were less major complications (p = 0.004) and mortality (p = 0.049) in the laparoscopic group. Two recurrences were reported in the laparoscopic group, although statistically not significant (p = 0.202).

CONCLUSIONS

Laparoscopic repair can achieve a shorter hospital stay and has lesser major complications and mortality in selected patients.

Transabdominal preperitoneal repair for obturator hernia

BACKGROUND

A laparoscopic surgical approach for obturator hernia (OH) repair is uncommon. The aim of the present study was to assess the effectiveness of laparoscopic transabdominal preperitoneal (TAPP) repair for OH.

METHODS

From 2001 to May 2010, 659 patients with inguinal hernia underwent TAPP repair at in our institutes. Among these, the eight patients with OH were the subjects of this study.

RESULTS

Three of the eight patients were diagnosed as having occult OH, and the other five were diagnosed preoperatively, by ultrasonography and/or computed tomography, as having strangulated OH. Bilateral OH was found in five patients (63%), and combined groin hernias, either unilaterally or bilaterally, were observed in seven patients (88%), all of whom had femoral hernia. Of the five patients with bowel obstruction at presentation, four were determined not to require resection after assessment of the intestinal viability by laparoscopy. There was one case of conversion to a two-stage hernia repair performed to avoid mesh contamination: addition of mini-laparotomy, followed by extraction of the gangrenous intestine for resection and anastomosis with simple peritoneal closure of the hernia defect in the first stage, and a Kugel hernia repair in the second stage. There was no incidence of postoperative morbidity, mortality, or recurrence.

CONCLUSIONS

Because TAPP allows assessment of not only the entire groin area bilaterally but also simultaneous assessment of the viability of the incarcerated intestine with a minimum abdominal wall defect, we believe that it is an adequate approach to the treatment of both occult and acutely incarcerated OH. Two-stage hernia repair is technically feasible in patients requiring resection of the incarcerated intestine.

Obturator hernia: the Mayo Clinic experience

BACKGROUND

Obturator herniae (OH) are rare, with nonspecific signs and symptoms, and diagnosis is usually delayed until laparotomy. The added benefit of preoperative diagnosis with computed tomography (CT) remains unclear.

METHODS

We reviewed the clinical characteristics and outcomes of OH repairs performed at our institution over a 58-year period. Outcomes were compared between patients who did or did not have a preoperative CT.

RESULTS

Between 1950 and 2008, 30 patients (median age 82 years, 29 women) underwent OH repair. The most common presenting signs and symptoms were bowel obstruction (63%), abdominal/groin pain (57%), and a palpable lump (10%). The pathognomonic Howship-Romberg sign was present in 11 patients (37%). The diagnosis was made preoperatively in nine patients: clinically in one (3%) and with CT in eight (27%). Nineteen patients (63%) presented emergently. Primary and prosthetic repair were performed in 23 (77%) and seven (23%) patients, respectively. Small-bowel resection was performed in 14 patients (47%). Perioperative morbidity (30%) and mortality (10%) rates were high. Patients with a preoperative CT were less likely to develop a postoperative complication of any type [odds ratio (OR) 0.8, P = 0.04]; however, time to operation, length of stay, need for bowel resection, and mortality rate did not differ (P = NS). No recurrences were detected at a median follow-up of 2 years (range 0-55).

CONCLUSION

Although CT imaging provides an excellent means of preoperative diagnosis, suggestive signs and symptoms in a "skinny old lady" should prompt immediate operative intervention without delay.

Obturator Hernia Revisited: Surgical Anatomy, Embryology, Diagnosis, and Technique of Repair

Obturator hernia is the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator canal. The first case was published by de Ronsil in 1724. Obturator hernia is more common in older malnourished women due to loss of supporting connective tissue and the wider female pelvis. The hernia sac usually contains small bowel, especially ileum. It may follow the anterior or posterior division of the obturator nerve. In most cases, obturator hernia presents with intestinal obstruction of unknown cause. It may present with obturator neuralgia, as a palpable mass or, in cases of bowel necrosis, as ecchymosis of the thigh. A correct diagnosis is made in 20 to 30 per cent of cases. CT scan is considered the gold standard for diagnosis, whereas ultrasonography, contrast studies, herniography and plain films are less specific. Surgery is the only treatment option for obturator hernia. Hesitancy to intervene surgically for chronically ill patients results in high mortality. Transabdominal approach is indicated in cases of complete bowel obstruction or suspected peritonitis. The extra-abdominal approach is used in preoperatively diagnosed cases and in absence of bowel strangulation. The laparoscopic approach is minimally invasive and effectively reduces morbidity. The defect is closed using sutures, tissue flaps, or prosthetic mesh.

Diagnosis and management of obturator hernia: an analysis of 15 cases

AIM: To explore the etiological factors, diagnosis, and management of obturator hernia.

METHODS: The clinical data for 15 patients with obturator hernia who received laparotomy from Aug 2000 to Aug 2010 were analyzed retrospectively.

RESULTS: All patients presented with acute intestinal obstruction. Seven patients underwent an abdominal CT scan, and five of them had obturator hernia. One case was misdiagnosed as perforated gastroduodenal ulcer and nine as mechanical intestinal obstruction. Twelve patients received emergency laparotomy. Three operations were performed 18, 24, and 37 hours after admission, respectively. Incarcerated small bowel was noted in all patients. Richter hernia was seen in seven cases. Anastomosis was carried out in five cases, and ileostomy in one case after resection of necrotic intestine. Obturator canal defects were repaired with figure-of-eight suture. Three patients suffered from pulmonary infection after operation. One patient suffered from wound infection, and one from multiple organ dysfunction syndrome. All patients were cured, and no recurrence was seen in 12 patients in the follow-up period ranging from 8 months to 7 years.

CONCLUSION: Emaciated elderly multiparous women suffering from sudden intestinal obstruction without definite reasons should be highly suspicious for obturator hernia. The Howship-Romberg sign, Hannington-Kiff sign, and CT scan are helpful to make a correct diagnosis. Early surgical intervention to relieve bowel incarceration is the exclusive therapy for the disease.

Obturator hernia: anatomy, embryology, diagnosis, and treatment

An obturator hernia is an infrequent but significant cause of intestinal obstruction. The incidence of obturator hernias is between 0.05 and 1.4% of all hernias. The mortality rate can be as high as 70% when acutely incarcerated due to the difficulty in diagnosis and delay in surgical treatment Three progressive stages of obturator herniation have been classified and can be one of three different varieties depending on the pathway the herniated sac follows. Knowledge of the anatomy and pathogenesis of obturator herniation is essential in diagnosis and treatment. The most common clinical presentation is intestinal obstruction (90%) and this is often seen in elderly, emaciated, multiparous women with predisposing conditions. Other classic signs, though not always present include obturator neuralgia, the Howship-Romberg sign and the Hannington-Kiff sign. Computed tomography scan is the most favored diagnostic imaging method. The abdominal surgical approach is most preferred when a diagnosis is uncertain and laparoscopy should be employed in elective early surgeries. This aim of this article is to review the diagnosis and treatment of obturator hernia by describing the anatomy, embryology, clinical presentation, diagnosis, and management currently in use. Increased awareness and proper management of this condition will result in decreased morbidity and mortality.

Clinical images. Classic presentation of a type II obturator hernia

A type II obturator hernia is a rare clinical entity that may be found on imaging and at surgery, as seen in this case of a 91-year-old woman who presented to our emergency department. Images are presented with treatment choices and a brief discussion on different types of obturator hernias.