Difficult diagnosis: strangulated obturator hernia in an 88-year-old woman

Abstract

The obturator hernia is a rare type of hernia that can present a diagnostic challenge for the clinician. We report a case of an 88-year-old woman who presented with a history of right iliac fossa pain, bilious vomiting and diarrhoea. Non-specific findings on examination and blood tests made the diagnosis difficult, however, a CT scan of her abdomen revealed the site of the obstruction and the patient was taken to theatre for emergency surgery. We review the literature with focus on the diagnosis of obturator hernias and the different surgical approaches used. The authors believe that this case is of educational value to healthcare professionals, particularly those working in general practice, emergency departments and on surgical teams. It highlights to doctors that patients with incarcerated obturator hernias can present with or without overt signs of intestinal obstruction and emphasises the fact that an obturator hernia can be an important cause of intestinal obstruction in a thin, elderly woman.

Obturator hernia: a rare cause of bowel obstruction

“…After reduction of the hernia sac and its contents, simple closure of the hernial defect with interrupted sutures or placement of a synthetic mesh is the preferred method 4. Mesh repair is associated with lowest recurrence rates 8. Laparoscopic repair has been shown to produce less postoperative pain, fewer complications and shorter hospital stay 2 7 8 11…”

Strangulated obturator hernia as an unusual cause of small bowel obstruction

“…Unlike most other hernias, a palpable mass is present only in 20%, which makes early diagnosis challenging . A high index of suspicion is required for clinical pre‐operative diagnosis, although computed tomography has a 90% detection rate and is considered the gold standard for diagnosis . The presence of small bowel deep to the femoral triangle, between obturator externus and pectineus muscles, is diagnostic (Figs ) …”

“…Repair can be performed by direct suturing of the obturator foramen or with a mesh and can be performed by trans‐abdominal, retropubic or trans‐inguinal approaches . Laparoscopic methods have also been described .…”

“…Once diagnosed, urgent operation is advised because 50–75% of cases require small bowel resection for ischaemia . Recurrence at 3 years after primary repair is 22%, but this can be reduced to 0% if mesh is used …”

“…1 Obturator hernias more commonly occurs on the right due to the presence of the sigmoid colon on the left side but can be bilateral in up to 6% of cases. 3,4 The usual affected population are elderly thin patients who are suffering from malnutrition or emaciation, with women being affected up to nine times more often than men. 1,3,4 It is thought that this is due to a combination of anatomical factors, including the presence of a wider obturator foramen, enlarged obturator canals and a lack of protective pre-peritoneal fat.…”