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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 60-62

Case of Incarcerated Obturator Hernia Presenting as Sub-Acute Intestinal Obstruction - Case Study and Review of Literature


1 Senior Resident, Department of General Surgery, IGIMS, Patna, India
2 Additional Professor, Department of General Surgery, IGIMS, Patna, India
3 Associate Professor, Department of General Surgery, IGIMS, Patna, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Krishna Gopal
Additional Professor, Dept. of General Surgery, IGIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


A 73 year old female presented with Intestinal Obstruction and did not respond to conservative management. A 73 year old lady presented with unable to pass faeces and abdominal distension for 6 days for which she was admitted and conservative management was done with emphasis of Electrolyte correction and supportive management. An abdominal X-ray revealed 3-4 Air fluid levels and the patient was passing flatus and occasionally liquid stools. A CECT abdomen was done to rule out other causes of mechanical obstruction which revealed a right sided obturator hernia with dilated bowel loops and features of intestinal obstruction. Exploratory Laparotomy was done an ileal loop was seen herniating into the bony foramen which could not be reduced. A separate incision was given on the Right Groin extending till the femoral region and hernia sac was reduced. A partial enterocoele (Richter's Hernia) was seen which became viable on warm compression. Obturator Foramen was closed and mesh plugging was done. Patient had uneventful smooth recovery and resumed normal oral diet after 48 hours. Patient was followed up for 3 months and was asymptomatic. The aim of this paper is to emphasize on the rarity of such conditions and discuss on the management with emphasis on the role of an early radiological diagnosis.

Keywords: Obturator hernia, Intestinal Obstruction, Laparotomy, Mesh plugging


How to cite this article:
Faiz N, Gopal K, Kumar M, Kumar M. Case of Incarcerated Obturator Hernia Presenting as Sub-Acute Intestinal Obstruction - Case Study and Review of Literature. J Indira Gandhi Inst Med Sci 2018;4:60-2

How to cite this URL:
Faiz N, Gopal K, Kumar M, Kumar M. Case of Incarcerated Obturator Hernia Presenting as Sub-Acute Intestinal Obstruction - Case Study and Review of Literature. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2021 Dec 4];4:60-2. Available from: http://www.jigims.co.in/text.asp?2018/4/2/60/302961




  Introduction: Top


Obturator hernia is a rare condition accounting for less than 1% of all intra-abdominal hernias. Clinical diagnosis is considered a challenge for most surgeons. It usually appears as an intestinal obstruction. Confirmation of diagnosis is carried out by means of CT imaging or during surgery. The obturator hernia affects typically women, elderly, multiparous, emaciated and those with increased intra-abdominal pressure[1]. Early diagnosis and surgical treatment are imperative and the delay is associated with a high mortality rate, increased complications rates and increased post-operative length of stay.


  Case Presentation: Top


A 73 year old lady presented with unable to pass faeces and abdominal distension for 6 days for which she was admitted and was kept on conservative management with emphasis of Electrolyte correction and supportive management in the Gastro-medicine department. Patient was transferred under the General Surgery department after a Surgical Consultation. Patient had no previous surgical history. Patient had stable vitals and general condition. There was history of nausea, vomiting, constipation, and lower right quadrant abdominal pain that radiated down the right medial thigh. There was some pain on medial aspect of thigh upon internal rotation of hip classically described as a Howship-Romberg sign. On examination her abdomen was soft, mildly distended, with tenderness on palpation of the right iliac fossa, but clinically she exhibited no masses and had clear hernia orifices. Bowel sounds were sluggish. No inguinal hernias were present. Erect abdominal x-ray revealed 3 -4 air-fluid levels without much bowel dilatation and the patient was passing flatus and occasionally liquid stools. Since the Patient was not responding to conservative management but was passing occasional liquid stools, a CECT abdomen was done to rule out other causes of mechanical obstruction. CT scan revealed a right sided obturator hernia [Figure 1] with a gut loop herniating into the obturator foramen with dilated bowel loops proximal to herniation and collapsed loops distally with other and features of
Figure 1: CECT abdomen showing an intestinal loop herniating through the right obturator foramen.

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Once the diagnosis was confirmed, an Informed consent was taken and an urgent Exploratory Laparotomy was done, an ileal loop was seen herniating into the bony foramen which could not be reduced even after releasing the adhesions around the foramen and incising the fascia. A separate incision was given on the Right Groin below the inguinal ligament extending up till the femoral region and whitish hernia sac was seen just inferior to the pectineus muscle [Figure 2].
Figure 2: White coloured hernia sac seen in the groin region which was dissected and released.

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The sac was incised and after adhesiolysis, the gut contents were reduced back into the abdomen. A partial enterocoele (Richter's Hernia) was seen [Figure 3] which became viable on warm compression.
Figure 3: Showing a Richter's Hernia which became viable after reduction and warm compression.

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Obturator Foramen was closed internally with 2/0Vicryl suture and mesh plugging was done externally with a pectineus flap. Patient had uneventful smooth recovery and resumed normal oral diet after 48 hours. Patient was followed up for 3 months and was asymptomatic.


  Discussion: Top


Obturator hernia is a rare condition accounting for less than 1% of all intra-abdominal hernias[1]. Arnaud de Ronsil first described the obturator hernia in 1724 and Obre performed the first successful operation in 1851. It occurs when abdominal viscera traverses the obturator canal through which the nerve and the obturator vessels pass[2]. This type of hernia is 6-9 times more common in women because of their broader pelvis and greater transverse diameter[3]. Other risk factors strongly related to obturator hernias are: elderly, emaciated, multiparous and patients with increased intra-abdominal pressure (chronic obstructive pulmonary disease and intestinal constipation). The condition has been nicknamed the ‘little old ladies hernia’ as it affects this group due to atrophy and loss of the pre-peritoneal fat around the obturator vessels in the canal predisposing hernia formation. Such factors can cause loosening of the pelvic floor that favours the onset of the hernia. It is less common on the left side because of the protection that sigmoid colon provides for the obturator canal[3] and can be bilateral in 20% of the cases. Obturator hernias are frequently associated with Richter hernia.

Accurate pre-operative diagnosis is difficult and occurs in less than 10% of the cases. Specific signs and symptoms are not common. Vomiting, lower abdominal pain and symptoms of intestinal obstruction are clinical findings. The Howship-Romberg sign (described as pain exacerbated by extension, abduction and internal rotation of the hip due to compression of the obturator nerve) is considered pathognomonic, although it is reported to be present in only 15-50% of cases.

CT scan is the most accurate imaging instrument for diagnosis in emergency room. It can help in pre-operative diagnosis, reducing the time between admission and treatment[4],[5]. CT imaging of bowel herniating through the obturator foramen and lying between the pectineus and obturator muscles is shown to be the best diagnostic clue[6]. This is demonstrated clearly by the CT image in [Figure 2].

Surgical intervention is the definitive management of an obturator hernia causing small bowel obstruction; both laparoscopic and open techniques have been demonstrated. In cases of emergency admission with small bowel obstruction the standard operation would be a laparotomy with an infra-umbilical midline incision, but there may be occasions when laparoscopy could be considered. Various surgical approaches have been described in the literature in the acute management of an obturator hernia. Abdominal, inguinal, retro-pubic, obturator, and laparoscopic approaches have all been described. The majority of published evidence favours the abdominal approach, utilising a low midline incision. This method allows the surgeon to establish the diagnosis, avoid any obturator vessels, give better exposure of the obturator ring, and facilitate bowel resection if necessary.[7]

Simple closure of the hernial defect with interrupted sutures or placement of a synthetic mesh are the preferred methods of herniorrhaphy as they are associated with the lowest complication rates.

We had a triple approach with internal closure using sutures, external closure using mesh plug and a pectineus flap to secure the defect


  Conclusion: Top


A high suspicion for obturator hernia should be maintained when assessing a patient presenting with bowel obstruction particularly where intermittent symptoms or medial thigh pain are present. A full assessment of the hernial orifices including screening for the Howship- Rhomberg sign should not be overlooked. The obturator hernia is a rare condition associated with a high rate of morbidity and mortality. Its diagnosis is considered a challenge because of its non-specific symptoms and signs and the low rate of occurrence compared to other abdominal hernias. Early CT scanning should be considered in cases where inguinal and femoral hernias have been ruled out by clinical examination. Lower midline infra- umbilical laparotomy is a safe and quick method to identify and repair an obturator hernia without complication. A laparotomy additionally allows inspection of the bowel for viability.



 
  References Top

1.
Killeen S., Buckley C., Smolerak S., Winter D. Small bowel obstruction secondary to right obturator hernia, Ireland. Surgery. 2013;157 (1):168  Back to cited text no. 1
    
2.
Igari K., Ochiai T., Aihara A., Kumagai Y., Iida M., Yamazaki S. Clinical presentation of obturator hernia and review of the literature. Hernia. 2010;14:409-413  Back to cited text no. 2
    
3.
Ng D.C.K., Tung K.L.M., Tang C.N., Li M.K.W. Fifteen-year experience in managing obturator hernia: from open to laparoscopic approach. Hernia. 2013;18:381-386.  Back to cited text no. 3
    
4.
Hunt L., Morrison C., Lengyel J., Sagar P. Laparoscopic management of an obstructed obturator hernia: should laparoscopic assessment be the default option? Hernia. 2009;13:313-315  Back to cited text no. 4
    
5.
Yokoyama Y., Yamaguchi A., Isogai M., Hori A., Kaneoka Y. Thirty-six cases of obturator hernia: does computerised tomography contribute to postoperative outcome? World Journal of Surgery. 1999;23:2144-2147  Back to cited text no. 5
    
6.
Jamadar D., Jacobson J., Morag Y., Girish G., Ebrahim F., Gest T. Sonography of inguinal region hernias. American Journalism Review. 2006;187:185-190.  Back to cited text no. 6
    
7.
Mantoo S.K., Mak K., Tan T.J. Obturator hernia: diagnosis and treatment in the modern era. Singapore Medical Journal. 2009;50(9):866  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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