STRANGULATED OBTURATOR HERNIA - A RARE CASE OF INTESTINAL OBSTRUCTION AND REVIEW OF THE LITERATURE

Tudor  Bratiloveanu; Sarmis  Săndulescu; Silviu Daniel  Preda; Adrian  Dobrinescu; Valeriu  Șurlin

doi:10.33695/rojes.v5i2.78

Tudor Bratiloveanu University of Medicine and Pharmacy of Craiova & Craiova Emergency Clinical County Hospital
Sarmis Săndulescu University of Medicine and Pharmacy of Craiova & Craiova Emergency Clinical County Hospital
Silviu Daniel Preda University of Medicine and Pharmacy of Craiova & Craiova Emergency Clinical County Hospital
Adrian Dobrinescu University of Medicine and Pharmacy of Craiova & Craiova Emergency Clinical County Hospital
Valeriu Șurlin University of Medicine and Pharmacy of Craiova & Craiova Emergency Clinical County Hospital

DOI: https://doi.org/10.33695/rojes.v5i2.78

Keywords: strangulated, obturator, hernia, intestinal, obstruction

Abstract

Comprising merely 1% of all abdominal wall hernias, obturator hernias exhibit a notable morbidity and mortality, with reported rates ranging from 15-25%, and in certain instances, escalating up to 70%. We present the case of a 79-year-old thin, frail lady who was admitted with a 5-day history of nausea, vomiting, constipation, and lower left quadrant abdominal pain that radiated down the left medial thigh. Howship-Romberg sign was positive. Plain X-rays revealed dilated bowel loops with multiple central air-fluid levels suggestive of complete small bowel (SB) obstruction with no signs of perforation. An urgent CT scan of the abdomen and pelvis was performed which found a dilated SB loop with a transition point caused by herniation through the left obturator foramen, suggestive of a strangulated obturator hernia. Decision to take the patient to surgery was adopted. After laparotomy, a segment of ileum was strangulated in the left obturator foramen. The SB segment was freed and found to be viable. A plug mesh repair was performed. This case report highlights the importance of considering obturator hernia in elderly, thin, multiparous women with chronic health conditions presenting with symptoms such as bowel obstruction or thigh pain. The diagnostic utility of imaging modalities, particularly CT scans, is crucial in accurately identifying obturator hernias preoperatively. Surgical intervention remains the mainstay of treatment, with a lower midline laparotomy being the preferred approach in emergency situations.

References

C. Y. Lo, T. G. Lorentz, and P. W. Lau, “Obturator hernia presenting as small bowel obstruction,” Am. J. Surg., vol. 167, no. 4, pp. 396–398, Apr. 1994, doi: 10.1016/0002-9610(94)90123-6.
[2] A. Petrie, R. S. Tubbs, P. Matusz, K. Shaffer, and M. Loukas, “Obturator hernia: anatomy, embryology, diagnosis, and treatment,” Clin. Anat. N. Y. N, vol. 24, no. 5, pp. 562–569, Jul. 2011, doi: 10.1002/ca.21097.
[3] J. D. Gilbert and R. W. Byard, “Obturator hernia and the elderly,” Forensic Sci. Med. Pathol., vol. 15, no. 3, pp. 491–493, Sep. 2019, doi: 10.1007/s12024-018-0046-z.
[4] E. T. Mindaye, D. Giduma, and T. H. Tufa, “Obturator hernia: case report,” J. Surg. Case Rep., vol. 2020, no. 10, p. rjaa389, Oct. 2020, doi: 10.1093/jscr/rjaa389.
[5] P. H. Schmidt, W. J. Bull, K. M. Jeffery, and R. G. Martindale, “Typical versus atypical presentation of obturator hernia,” Am. Surg., vol. 67, no. 2, pp. 191–195, Feb. 2001.
[6] N. C. Sá, V. C. M. Silva, P. R. L. Carreiro, A. S. Matos Filho, and I. A. Lombardi, “Rare case of incarcerated obturator hernia: Case report and review of literature,” Int. J. Surg. Case Rep., vol. 37, pp. 157–160, 2017, doi: 10.1016/j.ijscr.2017.06.024.
[7] G. O’Connell and A. Cole, “Obturator hernia: diagnosis through medical imaging,” Australas. Radiol., vol. 39, no. 3, pp. 306–308, Aug. 1995, doi: 10.1111/j.1440-1673.1995.tb00300.x.
[8] H. Funakoshi, “Point of care ultrasound for diagnosis of obturator hernia,” Acute Med. Surg., vol. 7, no. 1, p. e547, Jul. 2020, doi: 10.1002/ams2.547.
[9] R. Ijiri, H. Kanamaru, H. Yokoyama, M. Shirakawa, H. Hashimoto, and G. Yoshino, “Obturator hernia: the usefulness of computed tomography in diagnosis,” Surgery, vol. 119, no. 2, pp. 137–140, Feb. 1996, doi: 10.1016/s0039-6060(96)80160-7.
[10] S. S. Li and V. K. K. Ti, “Two Different Surgical Approaches for Strangulated Obturator Hernias,” Malays. J. Med. Sci. MJMS, vol. 19, no. 1, p. 69, Mar. 2012.
[11] J. Park, “Obturator hernia,” Medicine (Baltimore), vol. 99, no. 34, p. e21701, Aug. 2020, doi: 10.1097/MD.0000000000021701.
[12] C. C. Rito, J. Travassos, J. PatrÃcio, and A. L. Duarte, “Obturator hernia: a rare cause of bowel obstruction,” BMJ Case Rep., vol. 2017, p. bcr2017219369, Jul. 2017, doi: 10.1136/bcr-2017-219369.
[13] B. M. de Kok, J. B. C. M. Puylaert, and F. M. Zijta, “Ultrasound-guided reduction of an incarcerated obturator hernia in an elderly patient,” J. Clin. Ultrasound JCU, vol. 46, no. 6, pp. 415–418, Jul. 2018, doi: 10.1002/jcu.22562.
[14] A. W. Yip, A. K. AhChong, and K. H. Lam, “Obturator hernia: a continuing diagnostic challenge,” Surgery, vol. 113, no. 3, pp. 266–269, Mar. 1993.
[15] G. Naude and F. Bongard, “Obturator hernia is an unsuspected diagnosis,” Am. J. Surg., vol. 174, no. 1, pp. 72–75, Jul. 1997, doi: 10.1016/S0002-9610(97)00024-X.
[16] B. Mahendran and P. P. Lopez, “Obturator Hernia,” in StatPearls, Treasure Island (FL): StatPearls Publishing, 2023. Accessed: Dec. 07, 2023. [Online]. Available: http://www.ncbi.nlm.nih.gov/books/NBK554529/