Chin Wan Leong, et al., BAOJ Surgery 2017, 3: 23: 024

BAOJ Surgery

Case Report

BAOJ Surgery, an open access journal Volume 3; Issue 2; 024

*Corresponding author: Chin Wan, Leong; Department of surgery, Cen-tro Hospitalar Conde S. Januario, Macau, China, Tel: +85366806163; E-mail: sikanleong@gmail.com

Sub Date: May 25, 2017, Acc Date: May 30, 2017, Pub Date: May 30, 2017.

Citation: Chin Wan Leong, Sut Sin Tong, Nim Choi and Heong Keong Pang (2017) A Diagnostic Challenge: Obturator Hernia. BAOJ Surgery 3: 024.

Copyright: © 2017 Chin Wan Leong, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

A Diagnostic Challenge: Obturator Hernia

Chin Wan Leong1*, Sut Sin Tong1, Nim Choi1 and Heong Keong Pang1

1Department of surgery, Centro Hospitalar Conde S.Januario, Macau, China

Abstract

Background

Obturator hernia is an extremely rare type of abdominal wall hernia, with an incidence of less than 1%. Early diagnosis of obturator hernia is difficult because of non- specific clinical features, which contribute to high morbidity and mortality.

Objective

The objective of this study aim in demonstrates the early diagnostic hints of obturator hernia.

Methods

Two patients both were old and emaciate women, with 85 and 93 years old body weight 35 and 40kg respectively. They suffered from bowel obstruction without previous abdominal operative history. Conservative management of bowel obstruction included fasting; nasogastric tube placement and fluid replacement were failing. Patient number one developed acute peritonitis secondary to incarcerated intestine. Pre-operative abdominal CT scan confirmed the diagnosis of obturator hernia under high alert of cases, which is focus on any suspected mass located in the oturator foreman.

Results

Both patients were received surgical repairmen of the obturator hernia with simple prolene suture after abdominal CT scan. Both patients release of bowel obstruction and passed gas in D2-3 post operation. Number one patient prolonged hospitalization due to heart insufficiency, whereas number 2 patient had unfortunate recurrence of disease 7 months postoperatively. Further laparotmy and mesh repairment accomplished.

Conclusion

Obturator hernia occurs in elderly and emaciated woman. Acute intestinal obstruction is the most significant clinical presentation and half of patients complicate with small-bowel strangulation. Abdominal CT scan can accurately demonstrate a low- density mass that is a fluid-filled bowel loop or air filled, in the area of obturator foramen. The most critical hint is physician’s highly alert of the disease and application of abdominal CT scan subsequent;

thereby reduce the morbidity and mortality of obturator hernia.

Keywords: Obturator Hernia; Hernia; Small Bowel Obstruction

Introduction

Obturator hernia is a rare type of abdominal wall hernia with an incidence of 0.073% [1] to 1% of all abdominal wall hernias [2]. It may be due to the loss of supporting connective tissue and the wider female pelvis that obturator hernia is commonly seen in malnourished, multiparous, elderly women. It is defined by protrusion of the intra-abdominal viscera into the obturator foramen adjacent to the obturator vessels and nerve. Due to nonspecific presenting symptoms and signs, diagnosis and management are often delayed with relative high morbidity and mortality. The authors reported two cases of right obturator hernia presented with intestinal obstruction.

Case Report

Case 1

85-year-old woman was admitted to a private hospital 10days ago due to cough and fever with a diagnosis of respiratory tract infection. During hospitalization, she had vomiting and constipation for 2 days. Abdomen X-ray suggested intestinal obstruction. Nasogastric tube was inserted but without any improvement. Then, she was transferred to our hospital. The patient had history of hyperthyroidism, a trial fibrillation and chronic heart failure. She denies history of abdominal operation. The body weight was only 35Kg. Physical examination revealed a distended abdomen with

Citation: Chin Wan Leong, Sut Sin Tong, Nim Choi and Heong Keong Pang (2017) A Diagnostic Challenge: Obturator Hernia. BAOJ Surgery 3: 024.

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diffuse tenderness and absent of muscle guarding. Bowel peristalsis (Figure 1) was visible and weak bowel sound was noted. No mass was palpated in the bilateral groin but mild tender on right groin. Besides, rectal examination also found mild tender on right side of pelvic. How ship-Romberg sign was positive whereas Hannington-Kiff sign was negative. Plain abdominal radiography revealed dilated loops of small intestines (Figure 2). Enhanced Computed tomography (CT) scan demonstrated small bowel obstruction with a low density mass in the right obturator canal area (Figure 3). Right obturator hernia was confirmed and emergency laparotomy exploratory was proceeding. The abdominal cavity was entered via a sub-umbilical midline incision. During the operation, one short loop of ileumnear ileocecal valve was revealed herniated into the right obturator canal. Proximal intestine dilated severely and distal intestine collapsed. The incarcerated intestine was reduced and a perforated lesion was noted. Intestinal segmentectomy and simple suture of obturator foramen were performed. Patient recovered well in the abdominal situation. She passed gas in day 3 post operations and tolerated feeding very well. Remove abdominal suture in day 9 post operation without wound infection. She

prolonged hospitalization to 15 days because of heart insufficiency.

Case 2

93 year’s old, female. Her complaint of vomiting coffee-ground liquid. She had no fever, no diarrhea or abdominal pain. Physical examination only found mild abdomen distention. Body weight is 40Kg. Both Howship-Romberg sign and Hannington-Kiff sign are negative. Urine examination suggested urinary tract infection. Abdomen X-ray (Figure 4) showed small bowel dilatation. She denied history of abdominal operation. She was admitted to internal medicine with a diagnosis of urinary tract infection. But the patient persisted in vomiting and starts abdominal pain after 3 days of antibiotics. Further abdominal and pelvic CT scan was performed and found right obturator hernia. Diagnostic laparoscopy was done and confirmed the diagnosis (Figure 6). Simple closure the obturator foramen with Prolene pursing suture was done under laparoscopy. The patient recovered well and discharges after 5 days. However she was found hernia recurrent presented with small bowel obstruction again after 7 months of the first operation. She received laparotomy through midline incision

Bowel peristalsisFigure 1

Abdomen X-ray showed small bowel dilatation.

Figure 2

CT: a mass located between obturator externus muscles and ipsolateral pectineus.Arrow: small bowel

Figure 3

Abdo-men X-ray: Dilatation of small

bowelFigure 4

CT: Right obturator herniaFigure 5

Intraoperation laparoscopy photo1. Part of small bowel incarcerated in obturator foremen2. After reduction of the small bowel, obturator foremen seen3. Post simple closure the obturator foremen

Figure 6

Citation: Chin Wan Leong, Sut Sin Tong, Nim Choi and Heong Keong Pang (2017) A Diagnostic Challenge: Obturator Hernia. BAOJ Surgery 3: 024.

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and repaired the hernia with mesh. She recovered uneventful and discharge recently. No any complication happened in follow up.

Discussion

Obturator hernia is an uncommon internal hernia. In our index cases, both patients are old female and malnourished women suffered from right side obturator hernia. Incidence of obturator hernia is six times more common in women [3.4]. Anatomical differences between men and women are critical reasons. It is broaden understanding that female pelvis is wider, more oblique and larger in transverse diameter of the obturator foramen than male pelvis. Besides, multiplies pregnancies and deliveries increase weakness of the pelvic tissue also responsible for obturator hernia [4] On the other hand, right side obturator hernia is more common than left side obturator hernia, which attributes to protection by the sigmoid colon.

Base on relevance of the obturator nerve, obturator hernia is di-vided into two types type I: hernia sac locates in the anterior aspect of obturator nerve whereas type II is posterior. In our index cases, number 1 patient was type 1 and number 2 patient was type 2 [5].

About 90 % [6] of obturator hernia presents with intestinal ob-struction which is consistent with our cases. The clinical presenta-tion is non-specific gastrointestinal symptoms, including anorexia, weight loss and emaciation. There are two signs: Howship-Romberg sign and Hannington-Kiff sign, but only present in approximately 15%-50% of patients [7,8]. Howship-Romberg sign is ipsilateral pain along the inner thigh that is exacerbated by extension, ad-duction, or medial rotation of the hip and relieved by flexion. The Hannington-Kiff sign, more specific than the Howship-Romberg sign, refers to an absent adductor reflex in the thigh [8]. In our cas-es, number 1 patient presented with Howship-Romberg sign but both were absent of Hannington-Kiff sign among above two cases.

Due to its nonspecific symptoms, early diagnosis of obturator hernia is challenging.

There is no difference in clinical features and complication in both types of obturator hernia [4]. In literature review, only 10% of cases were lucky diagnosis before surgical intervention [9]. The diagnosis is often delayed or missed thereby results in high rates (50%) of bowel strangulation [9]. The morbidity has been reported about 30% (10)and mortality about 10% to 25% [10,11] in complicated obturator hernia. In our index cases, both patients are delay or misdiagnosis and complicated with small bowel obstruction and bowel strangulation, respectively.

A preoperative diagnosis can be made with diagnostic imaging methods, such as ultrasonography and CT scan. Ultrasonography might be limited in diagnosis because of high operator dependence and lead to only 30% of specificity [12]. CT scan is regarded as the

gold standard diagnostic modality for obturator hernia according to its high sensitivity and specificity, with a high accuracy more than 90% [12]. Our index cases were both diagnosed by CT scan before operation. The authors recommend early abdominal and pelvic CT scan for any suspected small bowel obstruction patient. Make attention to the obturator foramen is dispensable in such kind of cases.

The treatment of Obturator hernia is only surgically repairment. There is variety of operative approaches: abdominal, retro pubic, obturator, inguinal and laparoscopic. It depends by the patient’s condition and surgeon’s preference. Many authors prefer a simple closure of the intra abodminal defect as it leads to an acceptable recurrence rate of less than 10 % [13]. In contrast, repair with mesh maybe a good choice and more safety [3]. There is no randomized trial compare with simple suture to mesh in literature due to rare incidence. In our cases, we used only simple suture to close the defect of the obturator foramen because of strangulation of bowel, which increase risk infection if utility of mesh reparirment. However, there was hernia recurrence after 7 months of simple repairment in our case 2. Open right obturator hernia repair with mesh was done without complication. The authors recommend repair obturator hernia with mesh if possible.

Conclusion

Obturator hernias are rare and typically affect elderly and frail women. The symptoms are vague and physical examination is seldom useful. For all small bowel obstruction patients without specific finding during physical examination and without previous abdomen surgery, early CT scan is highly recommended due to high morbidity and mortality after delay diagnosis. Surgical repair is the only method. References

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Citation: Chin Wan Leong, Sut Sin Tong, Nim Choi and Heong Keong Pang (2017) A Diagnostic Challenge: Obturator Hernia. BAOJ Surgery 3: 024.

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8. Hannington-Kiff JG (1980) Absent thigh adductor reflex in obturator hernia. Lancet 1: 180.

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