Diagnostic difficulties in obturator hernia: a rare case presentation and review of literature

Abstract

Hernia arising from obturator canal is rare and it contributes to about less than 1% of incidence of all hernias. Diagnosing an obturator hernia clinically is a challenging one and nearly impossible. These hernias usually present as an intestinal obstruction as more than 50% of obturator hernias goes in for strangulation. Here, we report an unusual presentation of an obturator hernia in a 70-year-old woman who presented to emergency room with acute abdomen and uncomplicated reducible inguinal hernia. Radiological imaging showed obstructed inguinal hernia while on diagnostic laparoscopy, a strangulated and perforated obturator hernia of Richter’s type was seen in addition to an uncomplicated inguinal hernia. Obturator hernia, although very rare, is associated with high morbidity and mortality as it is often underdiagnosed as in our case. Laparoscopy bailed us out from missing out a perforation from an occult obturator hernia.

An unusual case of early-stage obturator hernia causing bowel obstruction and strangulation

“…Therefore, obturator hernias are often referred to as “little old lady's hernias” because women in this group have a larger pelvic diameter, larger obturator canal, and increased laxity of the pelvic tissues, and also experience atrophy and loss of preperitoneal fat around the obturator blood vessels in the obturator canal [3] . The risk factors for obturator hernia are constipation, chronic obstructive pulmonary disease, multiparity, ascites, aging, malnutrition, and increased intra-abdominal pressure [ 4 , 5 ]. Our patient in this case was also an elderly woman aged 77 years with multiparity risk factors, namely seven instances of childbirth.…”

“…In the case of obturator hernia, the CT scan can also aid rapid diagnosis and earlier surgery to optimize results and reduce mortality and morbidity [ 1 , 3 ]. The most frequent CT scan features are signs of obstruction and a herniated bowel loop through the obturator foramen between the obturator externus and the pectineus muscles [4] . In strangulated obturator hernia, a CT scan demonstrated edematous and ischemic small bowel, leading to perforation [3] .…”

Obturator hernia: a case report

“…CT scan can be especially useful in cases when physical examination is unrevealing or nonspecific [ 6 , 7 ]. Diagnostic laparoscopy can also serve as a tool during emergency repair by which to detect occult or missed hernias [ 8 ].…”

Richter's type of obturator hernia with Howship Romberg sign: a case report

“…The higher occurrence in women is believed to be due to the difference in anatomy of the female pelvis, where there is an increased transverse diameter and a steeper oblique orientation of the obturator canal. 5,8,9 An increase in the laxity of pelvic tissues secondary to atrophy of preperitoneal fat around the obturator vessels has been highlighted as a predisposing factor in the development of an obturator hernia. 5 This is frequently seen in underweight older women (70-90 years old); thus, the obturator hernia has been nicknamed the 'Little Old Lady's Hernia.…”