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The Little Ills Lady's Hernia: Obturator Hernia
Faisal El mouhafid*, Halim Mustapha, Njoumi Noureddine, Hajouji Abderrahmane, Mbarek Yaka, Aziz Zentar and Ait Ali Abdelmounaime
Department of Visceral Surgery, Mohammed V Military Teaching Hospital, Morocco
Received Date: 14/02/2022; Published Date: 25/02/2022
*Corresponding author: Faisal El mouhafid, Department of Visceral Surgery, Mohammed V Military Teaching Hospital, Ryad, Rabat, Morocco
Abstract
Obturator hernia is rare. It is the cause of 0.2 to 1.6% of mechanical occlusions of the small intestine. The mortality rate and morbidity after surgery is 35 and 18% respectively. We report the case of a patient in whom the diagnosis of strangulated obturator hernia was established as part of the assessment of an occlusion. HO is an entity whose preoperative diagnosis is difficult due to the low specificity clinical. The computed tomography examination seems to be a major aid in the etiological diagnosis. But once the diagnosis of occlusion has been made, a emergency intervention will make it possible to specify the etiology and to carry out the treatment. Any therapeutic delay increases mortality and morbidity.
Keywords: Hernia; Obturator; Strangulation
Introduction
An obturator hernia is defined as the outcome of part of the abdominal contents through the obturator canal [1,2]. it's a rare pathology. It represents 0.05 to 1.4% of all operated hernias and 0.2 to 1.6% of occlusions [2]. The purpose of this work was to consider the different clinical aspects, therapeutics and diagnostics of this rare variety of hernia.
Case Report
75-year-old women, mother of 5 children, presented to the emergency department presenting with abdominal pain of 24-h progression with food vomiting. She had a medical history: diabetes, high blood pressure, never operated. On examination, Glasgow coma score 15/15, respiratory rate: 16, saturations: 93%, blood pressure: 117/64, heart rate: 75, alert and temperature: 36.8 Celsius. she had a soft abdomen but was tender in the right iliac fossa. She had no palpable masses. Her blood tests were unremarkable and no signs of infection noted. ASP: hydro-aeric level. An abdominal scan was requested because an obturator hernia was suspected. An abdominal CT scan showed a right trans-obturator bowel loop. The serial reformatted CT scan showed an even better anatomical orientation (Figure 1). The patient underwent immediate surgery. A segment of the small intestine was incarcerated at the right obturator foramen (Figure 2) and was reduced smoothly. The incarcerated segment was found to be necrotic and perforated; a resection-anastomosis was performed the patient was discharged 5 days later.
Figure 1: An abdominal CT scan showed a right trans-obturator bowel loop.
Figure 2: A segment of the small intestine was incarcerated at the right obturator foramen.
Discussion
Obturator hernia is a rare abdominal hernia that is nonetheless a significant cause of morbidity and mortality. It occurs most frequently in emaciated patients between the age of 70 years and 90 years. Women are affected nine times more often than men because they have a broader pelvis with a larger triangular obturator canal opening, with a greater transverse diameter, and a history of pregnancy.
Therefore, this disease is nicknamed the “little old lady’s hernia”. It is estimated that a correct preoperative diagnosis is usually made in only 20e30% of cases of obturator hernia [3] because most patients have nonspecific symptoms and specific signs are often obscure.
Abdominal and pelvic CT scans is considered to be the standard means of preoperative obturator hernia diagnosis, with high sensitivity and specificity. Nishina et al [4] concluded that early diagnosis with a CT scan and subsequent surgery produced good results in these patients. They also recommended the use of early CT scans in thin, elderly women with small bowel obstruction [4].
Ultrasonography of the inguinal and inner thigh region is a fast and widely available imaging modality that can, in experienced hands, accurately diagnose potential bowel obstructions caused by an obturator hernia [5]. In addition to the main advantage of being readily performed in the emergency department or at the bedside, it also may show the degree of bowel dilation, the level of obstruction, the potential involvement of the large bowel, and the presence of bowel peristalsis. In the case of an incarcerated obturator hernia, a hypoechoic tubular structure or cystic lesion in the obturator canal region reflects a dilated, edematous bowel loop [5].
Although the incidence of obturator hernia in the general population is low, it is an important cause of intestinal obstruction, particularly in emaciated elderly women.
Because of its nonspecific presentation, delays in diagnosis, and the generally poor condition of the patients, postoperative morbidity and mortality are high. Ultimately, accurate diagnosis and immediate surgical intervention are essential to improving postoperative outcomes.
Laparoscopic surgery is becoming more popular when repairing obturator hernias and even cases of two-staged approaches are mentioned in literature [6]. This is due to the reduced postoperative recovery times due to fewer post-op complications, such as ileus, respiratory complications and pain [6]. A mesh or suture repair is performed if a defect is found to prevent reoccurrence [7]. The benefit of the mesh repair has generally outweighed the risk of infection, and a review of obturator hernia repair found a 0% reoccurrence rate for mesh repairs over 3 years [6].
Conclusion
Obturator hernias account for nearly 2% of mechanical small bowel obstruction and their mortality rate has been reported as nearly 50% in recent studies [7], We report this rare case as a reminder to health care colleagues working in primary and secondary care to acknowledge the importance of obturator hernias and appreciate the difficulties in diagnosis. CT scans remain the gold standard [8] and should be reviewed thoroughly.
References:
- Chang SS, Shan YS, Lin YJ, Tai YS, Lin PW. A Review of Obturator Hernia and a Proposed Algorithm for its Diagnosis and Treatment. World J Surg, 2005; 29 (4): 450-454.
- Hennekinne-Mucci S, Pessaux P, Du Plessis R, Regenet N, Lermite E, Arnaud JP. Hernie obturatrice étranglée: à propos de 17 cas. Annales de chirurgie, 2003; 128(3): 159-162.
- Maharaj D, Maharaj S, Young L, et al. Obturator hernia repairea new technique. Hernia, 2002; 6: 45e7.
- Nishina M, Fujii C, Ogino R, et al. Preoperative diagnosis of obturator hernia by computed tomography. Semin Ultrasound CT MR, 2002; 23: 193e6.
- Yokoyama T, Munakata Y, Ogiwara M, et al. Preoperative diagnosis of strangulated obturator hernia using ultrasonography. Am J Surg, 1997; 174: 76e8.
- Karasaki T, Nomura Y, Tanaka N. Long-term outcomes after obturator hernia repair: retrospective analysis of 80 operations at a single institution. Hernia, 2014; 18: 393–397.
- Chan KV, Chan CK, Yau KW, Cheung MT. Surgical morbidity and mortality in obturator hernia: a 10-year retrospective risk factor evaluation. Hernia, 2014; 18: 387–392.
- Ng DC, Tung KL, Tang CN, Li MK. Fifteen-year experience in managing obturator hernia: from open to laparoscopic approach. Hernia, 2014; 18: 381–386.
