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Obturator Hernia

Obturator hernia is a very rare form of hernia. It has a high rate of morbidity and mortality and the early diagnosis is considered a challenge because of the non-specific symptoms and signs.


Presentation

Obturator hernia has an incidence of 0.07–1% of all forms of hernias and accounts for 0.2–1.6% of all cases with mechanical obstruction of the small bowel. With the highest rate of mortality among hernias of the abdominal wall (13-40%), it also has a predilection for female patients and a female-to-male ratio of 6:1. Obturator hernia is sometimes referred to as "little old lady’s hernia" because it mostly affects elderly females due to atrophy of preperitoneal fat surrounding obturator vessels in the obturator canal. In 6% of cases, bilateral hernias can be detected. Obturator hernia generally presents as acute intestinal obstruction. In the majority of cases, the contents are small bowel. However, it may also contain omentum, appendix, or Meckel's diverticulum. The hernia sac follows the path of obturator nerves and muscles by passing through the foramen obturatum [1] [2].

Conditions causing a raised intra-abdominal pressure such as multiparity, ascites, chronic obstructive pulmonary disease (COPD) and constipation are other risk factors [3].

The clinical diagnosis is challenging because of rarity, deep location, and infrequent signs and symptoms. The physical examination is usually not contributory resulting in diagnostic delay. The hernial sac compresses and irritates the obturator nerve in the canal leading to medial thigh pain radiating down to the medial aspect of the knee and less frequently to the hip due to compression of the anterior division, a sign known as the Howship-Romberg sign. It is pathognomic of obturator hernia and is observed in 15–50% of cases. A palpable mass is identified in 20% of the patients in the medial proximal aspect of the thigh at the origin of the adductor muscles [2] [4]. When a patient presents with obstruction of the small bowel and intermittent symptoms with medial thigh pain, obturator hernia must be suspected.

The further symptoms are that of bowel obstruction, dull and crampy abdominal pain, nausea, and emesis. These symptoms are present in more than 80% of patients. Obstruction may be acute or intermittent [5].

Inguinal Mass
  • No palpable inguinal mass or hernia was found. A radiograph of the abdomen showed dilated loops of small bowel and multiple air–fluid levels suggestive of small-bowel obstruction ( Figure 1A ).[cmaj.ca]
Inguinal Pain
  • Contrary to what one might believe, and unlike usual inguinal hernia, the pubic inguinal pain syndrome does not show any visible swelling in the inguinal canal.[youcoach.it]
Hyperactive Bowel Sounds
  • There were hyperactive bowel sounds. No abnormal signs were found on rectal and vaginal examinations. Biochemical parameters were within normal limits. Plain abdominal radiography revealed multiple distended bowel loops.[oapublishinglondon.com]
  • There was diffuse abdominal distension and tenderness on palpation with hyperactive bowel sounds on auscultation. Initial abdominal radiographs dem?on?strated dilated loops of small bowel, consistent with obstruction.[hcplive.com]
  • Physical examination revealed an emaciated lady with a soft but distended abdomen, visible bowel coils, mild tenderness over the lower abdomen, and hyperactive bowel sounds. No mass or rebound pain of the abdomen was noted.[wjgnet.com]
Projectile Vomiting
  • An 81-year-old Caucasian emaciated female presented with 3 days history of colicky abdominal pain nausea, projectile vomiting and abdominal distension. A pre-operative diagnosis of mechanical bowel obstruction was made.[ncbi.nlm.nih.gov]
  • Physicians had ignored mild pain, projectile vomiting and failed to take surgical opinion in time. Upper gastrointestinal endoscopy showed some degree of reflux in lower end of oesophagus and antral gastritis.[casereports.in]
Persistent Vomiting
  • She was referred to surgery because of persisting vomiting, but without any abdominal pain. A CT scan showed a hernia in the right groin area but the diagnosis was delayed. The hernias were repaired using a preperitoneal transinguinal approach.[ncbi.nlm.nih.gov]
Hip Pain
  • Physicians should consider obturator hernia in the differential diagnosis of knee and hip pain, and investigate for Howship-Romberg sign.[ncbi.nlm.nih.gov]
  • We report an 86-year-old women with an obturator hernia presenting with recurrent right hip pain. Obturator hernia is a diagnostic challenge because the hernial mass is usually concealed beneath the pectineus.[ncbi.nlm.nih.gov]
  • The case of an elderly, emaciated female patient with recurrent lower abdominal and hip pain associated with nausea and vomiting due to an incarcerated obturator hernia is described.[ncbi.nlm.nih.gov]
  • Case Report An 86-year-old Caucasian female presented to hospital with a five-day history of vomiting, generalized colicky abdominal pain and constipation as well as right hip pain.[edoriumjournals.com]
  • She also complained of intermittent right hip pain with radiation to the medial aspect of the thigh for several months, which worsened with extension, abduction, or internal rotation of right leg.[medsci.org]
Thigh Pain
  • Based on our experience, when an elderly, thin, and parous woman presents with vomiting, abdominal or thigh pain, and intestinal obstruction, the differential diagnosis should include OH.[ncbi.nlm.nih.gov]
  • Obturator hernia presents subtly with medial thigh pain and no lump. They are notorious for difficulty to diagnosis.[ncbi.nlm.nih.gov]
  • After two months, she was admitted with left thigh pain. With these findings computed tomography scans confirmed left obturator hernia.[mona.uwi.edu]
  • Hernial sacs can irritate the obturator nerve within the canal, manifesting as medial thigh pain, and often no hernial masses can be detected on clinical examination.[ncbi.nlm.nih.gov]
  • Since the patient complained right medial thigh pain, we took a quick look of this area before ending the scan.[cmj.org]
Neglect
  • However, it presents in only 15–50% of the patients [1] and is almost neglected or misinterpreted as pain caused by osteoarthritis, a common ailment in the elderly.[cmj.org]
  • Zuptich Berberoglu states that "although these tiny anastomoses... have been described in classical anatomy textbooks, these texts neglect to mention that theses anastomoses can be life-threatening".[clinanat.com]
  • However, the Howship-Romberg sign was generally masked by the severe abdominal symptoms, and it was always neglected before operation. Another possible sign on presentation is the Hannington-Kiff sign[ 14 ].[wjgnet.com]
Opisthotonus
  • The diagnosis of tetanus was clinically made after the appearance of generalized spastic contractions with opisthotonus.[ncbi.nlm.nih.gov]

Workup

Several imaging methods have been used to diagnose the disorder including ultrasonography, plain radiography of the abdomen, and barium enema. Computed tomography (CT) of the abdomen and pelvis is the most relevant diagnostic tool. Recent reports have shown that a definite and early diagnosis of obturator hernia s possible by CT of the abdomen and pelvis [6] [7]. It is readily available, requires a short time, and is minimally invasive. CT scan can be especially helpful in the initial presentation when nonspecific signs and symptoms are identified [5].

The abdominal radiography often shows a nonspecific pattern of small bowel obstruction. Occasionally, gas shadows in the foramen obturatum or intraluminal air bubbles proximal to the superior ramus of the pubic bone will be diagnostic [8] [9]. On upper gastrointestinal tract series and barium enema, a loop of small bowel may be seen in the obturator canal [10].

Staphylococcus Aureus
  • In spite of this drainage, disseminated intravascular coagulation (DIC), necrotizing fasciitis, and methicillin-resistant Staphylococcus aureus (MRSA) infection were detected after surgery in four cases in which the thigh wound was closed, and two of[bmcsurg.biomedcentral.com]
Ischemic Changes
  • (Figure 3) The small bowel loop showed ischemic change but became revascularized again after reduction of the volvulus. The defect of the hernia was simply repaired with the interrupted Dexon suture. No resection of bowel loop was done.[ijcasereportsandimages.com]

Treatment

  • Knowledge of the anatomy and pathogenesis of obturator herniation is essential in diagnosis and treatment.[ncbi.nlm.nih.gov]
  • We suggest that a laparoscopic approach may be used as treatment, when a nonstrangulated obturator hernia is diagnosed preoperatively.[ncbi.nlm.nih.gov]
  • Preoperative diagnosis is still uncommon and influences treatment and prognosis. Clinical suspicion and tomography are fundamental for establishing a preoperative diagnosis.[ncbi.nlm.nih.gov]
  • The approach may be a better option for the treatment of incarcerated OH and occult hernias in selected patients.[ncbi.nlm.nih.gov]
  • The treatment is always surgical. There are several repair techniques that have been described: sac ligation alone, direct suture repair, use of autologous tissue or prosthetic repair.[ncbi.nlm.nih.gov]

Prognosis

  • Preoperative diagnosis is still uncommon and influences treatment and prognosis. Clinical suspicion and tomography are fundamental for establishing a preoperative diagnosis.[ncbi.nlm.nih.gov]
  • Signs of complication including: bowel obstruction strangulation resulting in perforation Treatment and prognosis Treatment involves surgery and repair of the hernial orifice.[radiopaedia.org]
  • The prognosis, despite our own results, remains severe for the compromised general conditions of the great majority of the patients.[biomedsearch.com]
  • Obturator hernia Microchapters Home Patient Information Overview Historical Perspective Pathophysiology Causes Differentiating Obturator hernia from other Diseases Epidemiology and Demographics Risk Factors Natural History, Complications and Prognosis[wikidoc.org]

Etiology

  • A 70 year old lady presented to surgery emergency with small bowel obstruction without any obvious etiology.[ncbi.nlm.nih.gov]
  • The preoperative diagnosis was intestinal obstruction of unknown etiology in 13 cases and intestinal obstruction due to obturator hernia in three (diagnosis by CT). The rate of strangulated hernias was 75% and the perforation rate was 56.3%.[ncbi.nlm.nih.gov]
  • Pelvic CT is almost 100% accurate in the diagnosis of obturator hernia and should be the modality of choice in older patients presenting with intestinal obstruction of unknown etiology.[ncbi.nlm.nih.gov]
  • ", keywords "Hernia, obturator, Intestinal obstruction etiology", author "B. Crespi and Villani, {R. D.} and O. Nucca and F. Varoli and G.[moh-it.pure.elsevier.com]
  • Contrast-enhanced computed tomography abdomen of the patient revealed evidence of small bowel obstruction, but no obvious etiology. Thus, the patient was taken for emergency laparotomy via midline vertical incision.[jpgmonline.com]

Epidemiology

  • Export Citation: APA/MLA Format Download EndNote Download BibTex MeSH Terms Descriptor/Qualifier: Female Hernia, Obturator / diagnosis*, epidemiology, physiopathology, surgery Humans Male From MEDLINE /PubMed , a database of the U.S.[biomedsearch.com]
  • Obturator hernia Microchapters Home Patient Information Overview Historical Perspective Pathophysiology Causes Differentiating Obturator hernia from other Diseases Epidemiology and Demographics Risk Factors Natural History, Complications and Prognosis[wikidoc.org]
  • Advanced Search EPIDEMIOLOGY OF INJURIES AND DISEASES DUE TO OVERUSE IN RUGBY: OBSERVATIONAL STUDY OF THE PLAYERS OF “CUS PERUGIA RUGBY” 05 March 2014 Rugby is a contact sport and for this reason is very demanding from a physical point of view.[journalmedica.com]
  • Current epidemiologic assessments suggest that gender distribution and anatomic distribution are similar to those in more developed countries. Age-related demographics The prevalence of all varieties of hernias increases with age.[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • Obturator hernia Microchapters Home Patient Information Overview Historical Perspective Pathophysiology Causes Differentiating Obturator hernia from other Diseases Epidemiology and Demographics Risk Factors Natural History, Complications and Prognosis[wikidoc.org]
  • Pathophysiology of gastroesophageal reflux: lower esophageal sphincter dysfunction in gastroesophageal reflux disease. Gastroenterol Clin North Am 1990; 19:571-535. ‎ Página 142 - Fry DE.[books.google.es]
  • PATOPHYSIOLOGY Many attempts have been made to explain the pathophysiological mechanisms that cause the pubic inguinal pain syndrome, like a weakness of the lower abdominal wall, an imbalance between the (strong) adductor muscles of the hip and the (weak[youcoach.it]
  • Pathophysiology Inguinal hernia The pinchcock action of the internal ring musculature during abdominal muscular straining prohibits protrusion of the intestine into a patent processus. Muscle paralysis or injury can disable the shutter effect.[emedicine.medscape.com]

Prevention

  • Early intervention can prevent the morbidity and mortality associated with complicated obturator hernia.[ncbi.nlm.nih.gov]
  • To prevent the recurrence, mesh repair is preferable if no contraindications are present.[ncbi.nlm.nih.gov]
  • Obturator hernia (OH), a rare cause of acute small bowel obstruction, requires immediate surgical intervention to prevent serious complications and mortality.[ncbi.nlm.nih.gov]
  • Secondary Prevention Cost-Effectiveness of Therapy Future or Investigational Therapies Case Studies Case #1 Obturator hernia CT On the Web Most recent articles Most cited articles Review articles CME Programs Powerpoint slides Images American Roentgen[wikidoc.org]
  • Treatment for an obturator hernia is surgery, typically using laparoscopy, to remove the hernia, and then sutures or a mesh patch are sometimes used to reduce the opening and prevent further herniation.[wisegeek.com]

References

Article

  1. Lo CY, Lorentz TG, Lau PW. Obturator hernia presenting as small bowel obstruction. Am J Surg. 1994;167:396–398.
  2. Hodgins N, Cieplucha K, Conneally P, Ghareeb E. Obturator hernia: a case report and review of the literature. Int J Surg Case Rep. 2013;4(10):889–892.
  3. De Clercq L, Coenegrachts K, Feryn T, et al. An elderly woman with obstructed obturator hernia: a less common variety of external abdominal hernia. JBR-BTR. 2010;93(6):302-4.
  4. Antoniou Z, Volakaki E, Giannakos E, Kostopoulos DC, Chalazonitis A. Intestinal obstruction due to an obturator hernia: a case report with a review of the literature. OA Case Reports. 2013;2(1):5.
  5. Mantoo SK, Mak K, Tan TJ. Obturator hernia: diagnosis and treatment in the modern era. Singapore Med J. 2009;50(9):866.
  6. Yokoyama Y, Yamaguchi A, Isogai M, et al. Thirty-six cases of obturator hernia: does computed tomography contribute to postoperative outcome? World J Surg. 1999;23:214-217.
  7. Dundamadappa SK, Tsou IY, Goh JS. Clinics in diagnostic imaging (107). Singapore Med J. 2006;47:88-94.
  8. Hsu CH, Wang CC, Jeng LB, et al. Obturator hernia: a report of eight cases. Am Surg. 1993;59:709-711
  9. Young A, Hudson DA, Krige JEJ. Strangulated obturator hernia: can mortality be reduced? South Med J. 1988;81:1117-1120.
  10. Carriquiry LA, Pineyro A. Pre-operative diagnosis of non-strangulated obturator hernia: the contribution of herniography. Br J Surg. 1988;75:785.

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Last updated: 2018-06-22 07:57