Laparoscopic management of incarcerated obturator hernia

Obturator hernia is a rare cause of obstruction of the small bowel. Various imaging modalities have been applied to achieve preoperative diagnosis of this rare clinical entity. Because there may be a potential for undue delay in the definitive treatment of patients with impending bowel strangulation, some health care workers have advocated that obturator hernia requires laparotomy more than a diagnosis.¹ Now, in this era of minimally invasive surgery, we can apply laparoscopy in the early diagnosis and treatment of this rare disease.

Case report

An 87-year-old resident of an old-age home was admitted to hospital because of colicky abdominal pain and vomiting for 1 day. She had no previous abdominal surgery. Physical examination revealed an emaciated lady with a distended abdomen and hyperactive bowel sounds. She showed Howship–Romberg sign: pain or parathesia along the medial side of the thigh during extension and abduction of the hip. An abdominal radiograph showed obstruction of her small bowel. The provisional diagnosis was incarcerated obturator hernia.

Laparoscopy was arranged promptly after fluid resuscitation. A “knuckle” of small bowel was found to be incarcerated to the right obturator foramen (Fig. 1). It was gently reduced with forceps, without trauma. After we carefully verified the viability of the incarcerated small-bowel loop, we closed the defects on both obturator foramena with broad ligaments by laparoscopic intracorporeal suturing using non-absorbable sutures (Fig. 2).

FIG. 1. Incarcerated small bowel at right obturator hernia.

FIG. 2. Repair of the hernia defect with broad ligament.

The operating time was 45 minutes, with minimal blood loss. The patient's postoperative recovery was uneventful. She was then discharged from the hospital 3 days after surgery and was still symptom-free 1 year later.

Discussion

Since the initial description of obturator hernia by de Ronsil in 1724, over 600 cases have been reported.² It frequently affects elderly multiparous women who have comorbidities. Many of these women are thin and are often under institutional care.³

Ultrasonography, herniography and small-bowel contrast-enhanced and computed tomography have been used for diagnosis, even though preoperative imaging could delay definitive treatment for the patient with acute small- bowel incarceration caused by an obturator hernia. It has been recommended that “obturator hernia needs a laparotomy, not a pre-operative diagnosis.”¹ With the advent of minimally invasive surgery, early laparoscopy assists in diagnosis and avoids delay of definitive operative care.

Several techniques to repair the obturator hernial defect have been described. In our case, broad ligaments were employed because in female patients they are readily available and close to the hernial defect(s).

In summary, obturator hernia is a rare cause of small-bowel obstruction in the elderly. Early diagnosis, reduction of the incarcerated small bowel, and repair of both obturator herniae can be achieved via laparoscopy.

Competing interests: None declared.

Correspondence to: Dr. K.K. Yau, Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, SAR, China; fax 852 25 153 195; wtsiu@netvigator.com

Accepted for publication Mar. 3, 2004