Laparoscopic management of obturator hernia in the setting of intestinal obstruction: A report of two cases and review of literature

Abstract

Owing to its rarity and non-specific clinical features, a diagnosis of obturator hernia is often delayed until the patient presents with intestinal obstruction. Often the diagnosis is made on a Computed Tomography (CT) scan or during exploratory laparotomy. While a laparoscopic approach is well described in an elective scenario, open surgery through a midline laparotomy has been the preferred approach for obturator hernia with intestinal obstruction. However, a few cases of obstructed obturator hernia have been reported that have been managed laparoscopically. We present our experience of two elderly patients who presented with intestinal obstruction. A CT scan helped clinch the diagnosis of obturator hernia as the cause and both were managed laparoscopically.

Introduction

Obturator hernias are rare accounting for 0.05–1.4% of abdominal wall hernias.¹ Even experienced surgeons may have managed only 1–2 cases in their entire career.² Owing to its non-specific clinical features, diagnosis is often delayed until surgery for bowel obstruction which may increase the mortality to up to 70%.³ A high index of suspicion for preoperative diagnosis and urgent surgery is the only management. When presenting with intestinal obstruction, conventional surgery has usually been advocated. However, there are only isolated reports of laparoscopic management in this scenario.^4,5 We report two cases of obturator hernia presenting to us in intestinal obstruction which was diagnosed preoperatively and managed laparoscopically.

Case report

Case 1

A 71-year-old frail, abdominal surgery-naïve female patient presented with colicky abdominal pain and constipation for three days and obstipation for one day. She had history of similar episodes during the past one year warranting repeated admissions elsewhere. Clinically, she was dehydrated and had a pulse rate of 96/minute and Blood Pressure (BP) was 90/60 mm Hg. The abdomen was distended; hernia sites were normal, and bowel sounds were exaggerated. She was kept nil per oral, a nasogastric tube (NG) placed; fluid resuscitation done and was started on antibiotics. A contrast enhanced computed tomography (CECT) abdomen was performed which showed an obstructed right obturator hernia (Fig. 1A). The patient was taken up for laparoscopic management. An obstructed obturator hernia was found which was reduced with gentle traction (Fig. 1B) when a small ileal perforation was noticed that was sutured with 3-0 polydiaxonone (PDS). The hernia sac was excised. In view of a focal ileal perforation with no contamination, a laparoscopic mesh plug repair of the obturator canal opening was performed and the peritoneum was closed over it with 2-0 PDS (Fig. 1C) (See video in supplementary file). Her postoperative period was uneventful, and she was discharged on postoperative day (POD) seven. On follow-up, she had no recurrence and was leading a good quality of life. Patient consent was obtained for images and inclusion in the study.

Fig. 1.

(A) Axial section of a CT scan showing the right obturator hernia (white star). (B) Obturator hernia being gently reduced. (C) Mesh plug repair in progress. (D) Picture of the patient's abdomen showing prominent distended bowel.

The following is/are the supplementary data related to this article:

Supplementary file

Operative video of laparoscopic management of obturator hernia presenting with intestinal obstruction.1

Case 2

A 69-year-old thin-built female patient presented with abdominal pain, vomiting and obstipation of four days' duration. She was dehydrated, had tachycardia and BP was 90/62 mm Hg. Abdominal examination revealed distended abdomen with prominent dilated bowel loops (Fig. 1D) and absent bowel sounds. The hernia sites were normal, and there were no scars of past surgery. A CECT abdomen showed an obstructed right obturator hernia.

On laparoscopy, the hernia was gently reduced to reveal a gangrene perforation in the obstructed ileal segment with localized faecal contamination. Segmental resection of the bowel and stapled anastomosis was performed. After peritoneal toileting, suturing of the hernial defect with 1-0 PDS was carried out. Unfortunately, on POD one, she had a cardiac event and deteriorated over the next 24 h and died.

Discussion

Obturator hernia is a rare pelvic hernia first described by Arnaud de Ronsil in 1724,⁶ and the first successful repair was performed by Henry Obre in 1851.⁷ Obturator hernia usually occurs in multiparous, frail, emaciated women, usually in their seventh and eighth decades, and thus has been given the name ‘the little old lady's hernia’. It is 6–9 times more common in women due to broader pelvis and horizontally inclined obturator canal.⁸

The clinical features of obturator hernia are often non-specific, and most patients present with small bowel obstruction. A past history of recurrent such episodes may be present in 30% of cases. A mass may be palpable in the proximal medial aspect of the thigh in 20%.⁹ The pathognomic Howship-Rhomberg sign, characterized by pain in the medial aspect of the thigh due to compression of obturator nerve upon extension, abduction and medial rotation of the ipsilateral lower extremity, can be demonstrated in only 15–50% of cases.¹⁰ The Hannington-Kiff sign has been found to be more specific.¹¹ Neither of our cases had a mass in the medial aspect of the proximal thigh nor did they have the Howship-Rhomberg sign.

It is said that a preoperative diagnosis is possible in only 20–30% of cases, and the diagnosis relies on a high clinical suspicion and prompt imaging.¹² In our cases, we decided to order CECT of the abdomen because they presented with intestinal obstruction, and in the absence of previous surgery, malignancy was suspected. In the second case, we did think of an obturator hernia because of the patient presenting in similar clinical settings as our first case. Abdominal CT scan has >90% accuracy in diagnosing obturator hernia and is considered the standard means of preoperative diagnosis.¹²

An urgent surgery is crucial because the rate of strangulation increases with delay and contributes to high mortality rates of up to 70%.³ A variety of operative approaches including inguinal, retropubic and transperitoneal have been described.^12,13 A conventional surgery using a lower midline incision is commonly used in emergency settings when patients present with intestinal obstruction. When reduction is difficult, options include incising the obturator membrane or injecting water through a thin catheter inserted into the sac to help reduce the incarcerated bowel.^13,14 Small defects can be repaired by simple suturing. Larger defects may require fascial closure or autologous tissue/prosthetic mesh reinforcement. Prosthetic mesh is contraindicated in spillage of bowel contents.

A laparoscopic approach is usually applied in elective settings, and reports of a laparoscopic approach to obturator hernia in the setting of obstruction/incarceration are few.^4,5 In an elective setting, both laparoscopic total extraperitoneal or transabdominal preperitoneal (TAPP) approaches are recommended. However, in the setting of intestinal obstruction, a TAPP approach is recommended as the reduced bowel can be inspected for gangrene/perforation. The TAPP approach also permits identification and repair of an occult contralateral obturator hernia which is reported to be present in 50–63%. A literature search revealed that there are only 30 cases that have been managed laparoscopically in the presence of bowel obstruction (Table 1).

Table 1.

Review of literature of all cases of obturator hernia with intestinal obstruction managed laparoscopically.

Sl no	Author	Year	No of cases	Bowel resection	Type of repair
1	Byrant16	1996	1	No	TAPP
2	Miki17	1998	1	Yes	TEP
3	L R Haith18	1998	1	No	TAPP
4	Shapiro19	2004	1	Yes	TEP
5	Wu20	2007	1	No	TAPP
6	Mantoo21	2009	1	No	TAPP
7	Hunt5	2009	1	No	TAPP
8	Sun HP22	2010	1	No	Suturing of defect and reinforced by broad ligament
9	Hayama S14	2015	6	2/6 cases	TAPP
10	Atsushi Kohga23	2017	1	No	TAPP
11	Liu J24	2017	9	1/9 cases	TAPP
12	Chihara25	2019	6	Not given	TEP/TAPP
13	Our series	2020	2	1/2 cases	Simple suturing of defect/mesh plug

TAPP, transabdominal preperitoneal repair; TEP, totally extraperitoneal repair.

In both our cases, we have demonstrated that a laparoscopic management is feasible even in the presence of intestinal obstruction. The port positions used were similar to those of the TAPP approach. We used the open technique to place our first 10-mm port at the umbilicus and pneumoperitoneum created which ensured a reasonable working space. The poor muscle tone of the abdomen in this subset of patients, perhaps, helps in creating more space as compared with younger patients. Instruments were carefully navigated over the dilated bowel, and the hernia was identified, reduced, sac excised and defect repaired. In the first case, we debated over a TAPP approach versus a mesh plug repair and chose the latter. This was a conscious decision because there was just a focal perforation with no contamination. Mesh plug repair for obturator hernia has been reported in the literature.¹⁵ In the second case, because of the fecal contamination, we chose to do a simple suture repair.

To conclude, obturator hernias, although rare, can be a frequent cause of small bowel obstruction in the clinical setting of an abdominal surgery-naïve, elderly, frail, female patients. A high index of suspicion and prompt imaging with a CT scan can help clinch a diagnosis and help early definitive management to reduce the high morbidity and mortality associated with delayed diagnosis. Finally, even in the presence of intestinal obstruction, laparoscopic management is feasible.

Disclosure of competing interest

The authors have none to declare.