Laparoscopic repair of an obturator hernia; a case report of a contemporary surgical technique

Abstract

Introduction and importance

Small bowel obstruction secondary to an obturator hernia is a rare presentation associated with high mortality. Prior to the development of laparoscopic surgery, a laparotomy would have been the management technique of choice for this rare presentation.

Case presentation

An elderly female with a bowel obstruction secondary to an obturator hernia presented via the Emergency Department. A laparoscopic approach with the use of a haemostatic gauze plug was performed to repair the defect.

Clinical discussion

The evolution of surgical techniques, particularly with laparoscopy has resulted in overall benefits regarding patient outcomes. These benefits include lower post operative morbidity, shorter length of stay and decreased post operative pain. This report discusses a laparoscopic approach and the use of a gauze plug to manage an emergent small bowel obstruction secondary to an obturator hernia.

Conclusion

The use of a haemostatic gauze agent is an alternate and potentially advantageous approach for an obturator hernia repair in the emergency setting.

Highlights

• •Bowel obstruction caused by an Obstructor Hernia is rare but it has a high risk of mortality
• •= contemporary surgical approach likely resulting in better post operative outcomes
• •A more accessible, arguably more affordable and less invasive surgical approach

1. Introduction

Prior to the age of elective hernia repairs, the commonest cause for bowel obstruction was abdominal hernias [1]. In medicine today, abdominal hernias are the third commonest cause for bowel obstruction, after adhesions and neoplasms [2]. And, of those, obturator hernias (OH) represent only 0.05 %–1.14 % of all abdominal hernias however, their mortality can be as high as 70% [3].

This case report discusses the benefits of laparoscopic approach to the obturator hernia repair and conveys the operative benefits of placing a soluble haemostatic gauze to close the defect (SCARE 2020) [4].

2. Presentation of case

We describe a case of an 87-year-old female who presented with a four-day history of generalised abdominal pain associated nausea, vomiting and two days of obstipation. Past medical history included bronchiectasis and chronic lymphocytic leukaemia (CLL). No previous abdominal surgeries.

On examination the patient was tall, cachectic, and deconditioned. They were hemodynamically stable; abdomen was distended, tender to palpation albeit soft with no clinical peritonism.

Biochemical investigations were unremarkable; potassium 3.3 (3.5–5), magnesium 0.95 (0.8–1), phosphate 0.94 (0.70–1) and lactate 0.9 (<1). Infective markers were unreliable given persistent leucocytosis secondary to CLL.

A CT scan showed a left sided obturator hernia with dilated loops of small bowel proximal to hernia (Fig. 1).

Fig. 1.

a Axial b coronial showing herniated bowel within obturator canal on the left side.

The patient was immediately managed with gastric decompression followed by discussion with the patient and their family regarding the necessity of urgent operative management.

Our approach was to attempt the operation laparoscopically in the initial instance with conversion to laparotomy if required. A supraumbilical 12 mm port via Hassan entry was used to establish a pneumoperitoneum and perform laparoscopy. At this point visualisation of the bowel was limited, a 12 mm working port was placed in the left flank and a further 5 mm working port placed into right hypochondrium.

The bowel was inspected using these ports (5 mm & supraumbilical 12 mm), and camera was placed into the left flank 12 mm port. At this point the decision was made to remove the obstructed bowel from the Obturator Canal with atraumatic bowel graspers and traction. This was achieved with no complication, that is, no perforation nor bleeding. The hernia contained a colonic epiploic appendix, this was overlying a section of small bowel causing contraction and therefore obstruction (Fig. 2a). The bowel was oedematous, however viable and did not require resection (Fig. 2b).

Fig. 2.

a Single contracture overlying area of small bowel.

b Infarcted epiploic appendix, closed obturator defect.

c Haemostatic gauze placed into defect.

We preceded at this point to place SURGICEL® haemostatic gauze (Ethicon, US) (plug mesh) into the defect, then using 2-0 V-lock™ barbed sutures (Medtronic, Minneapolis USA) we closed the peritoneum over the obturator defect (Fig. 2c).

Post operative day two the patient was passing flatus and tolerating clear fluids. Post operative day four the patient opened their bowels and tolerated a full diet. On post operative day eleven the patient was discharged home having returned to baseline.

3. Discussion

The high mortality rate for OH is due to the patient population who present with the condition and how they present. The patients are usually elderly, deconditioned and suffer from diseases with prolonged increased intra-abdominal pressure such as chronic lung disease or chronic constipation [5]. An OH is difficult to diagnose clinically as they can be associated with pain in the obturator nerve distribution, that is, the medial thigh or hip, or be insidious and instead present late as a bowel obstruction [6].

Obturator hernias require operative management, but how remains to evolve. A recent systematic review of obturator hernias found that laparoscopic approach decreased length of hospital stay, morbidity and post operative pain [7]. Laparoscopic approach therefore is particularly appropriate given the patient population who develop this hernia: elderly slender women with a chronic disease [7].

Our approach allows for a shorter operative time, which reduces anaesthetic time and therefore post operative morbidity. The operator requires no additional laparoscopic skills or technique to roll gauze and place the material into the defect. The material itself is easily accessible as it is commonly stocked in operating theatre storerooms, and furthermore affordable i.e. $21 AUD per sheet of 7.5 m × 10 cm in our centre.

4. Conclusion

The long-term result of placing a gauze plug is not fully known. As such, further long-term multicentre studies should be conducted in order to assess the risks and benefits of this technique. Regardless, a technique which allows for a shorter operative time is undoubtedly consequential in reducing the perioperative risk of morbidity and mortality.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval is exempt/waived at our institution.

Funding

There was no funding received for this research.

Guarantor

Dr Danjel Miladinovic.

Research registration number

0000-0001-9532-1189

CRediT authorship contribution statement

• Danjel Miladinovic (first author) wrote this paper and assisted in surgery described

• Kenneth Buxey (second author) edited this paper and was senior surgeon in surgery described.

Conflicts of interest

There are no conflicts of interests.