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Bilateral obturator hernia diagnosed by computed tomography: a case report with review of the literature.

1. Introduction

An obturator hernia is a rare cause of all abdominal wall hernias commonly seen in females. Its clinical diagnosis is often difficult due to uncommon incidence, its deep location, and infrequent symptoms and signs. Delay in its diagnosis causes poor prognosis with increased morbidity. Early CT imaging establishes diagnosis and detects asymptomatic contralateral obturator hernia. The following case report highlights these diagnostic difficulties and reviews the current literature on diagnosis and management of such cases.

2. Case Report

70-year-old known hypertensive female patient presented with intermittent abdominal pain and vomiting for 2 days. She gave past history of pulmonary Koch's 10 years back for which she completed AKT. On examination the patient was thin-built, conscious, and well oriented. Blood pressure was 150/90 mmHg. Respiratory rate was 22/min. Per abdomen examination showed mild abdominal distension. She was referred for USG Abdomen and Pelvis. USG Abdomen and Pelvis showed mild dilatation of small bowel loops in entire abdomen (caliber = 3-3.5 cm) with intermittent to-and-fro peristalsis. Mild free fluid was noted in pelvis and in between small bowel loops. Left inguinal and left upper thigh region showed a herniated small bowel loop extending in medial aspect of upper thigh which was irreducible. A diagnosis of obstructed and irreducible left femoral hernia was made. X-ray standing abdomen (Figure 1) revealed dilated small bowel loops in mid and lower abdomen with no pneumoperitoneum. She was referred for emergency plain CT scan of abdomen and pelvis. Small bowel loops in abdomen and pelvis appeared fluid-filled and dilated of caliber 3-3.5 cms (Figures 2(a) and 2(b)). There was herniation of a bowel loop of length 3.5 cm through left obturator foramen extending inferiorly between pectineus muscle anteriorly and obturator externus muscle posteriorly, suggestive of obturator hernia (Figures 3, 4(a), and 4(b)). Left pectineus muscle was compressed and displaced anteriorly. Few small bowel loops appeared collapsed; hence obstruction was likely to be at distal jejunum/proximal ileal level. Visualized colon appeared collapsed. Also, hernia of omentum/mesentery was noted from the right obturator foramen measuring approximately 2 x 0.9 cm. Herniated omentum/mesentery was seen to lie in between the pectineus muscle anteriorly and obturator externus muscle posteriorly (Figures 4(a) and 4(b)). No herniated bowel loop was seen through right obturator foramen in the present study. A diagnosis of obstructed left obturator hernia with proximal dilatation of small bowel loops and right obturator hernia containing omentum/mesentery was made.

Exploratory laparotomy was performed which confirmed obstructed left obturator hernia and the entrapped segment of bowel was released. Small bowel 100 cm proximal to ileocaecal junction was found to be gangrenous. Hence, resection anastomosis was done. Approximately 60 cm of small bowel was resected. Obturator hernia was also confirmed on right side containing mesentery. The hernial defect was covered on either side with prosthetic mesh. Care was taken not to damage the obturator nerve on either side while covering it with prosthetic mesh.

3. Discussion

Obturator hernias account for 0.07-1% of all hernias and 0.21.6% of all cases of mechanical obstruction of small bowel (Table 1). They have the highest mortality rate of all abdominal wall hernias (13-40%) with female predominance and with female to male ratio of 6: 1. Female preponderance is due to large and more oblique incline of obturator canal in female pelvis. It occurs more frequently on right side as sigmoid colon overlies left obturator foramen. Bilateral obturator hernias are seen in 6% of cases [1].

It is commonly seen in elderly females and postpregnancy patients due to greater width of the pelvis, larger obturator canal, and increased laxity of the pelvic tissues. It is nicknamed "little old lady's hernia" as it affects this group due to atrophy and loss of preperitoneal fat around obturator vessels in obturator canal predisposing to obturator hernia. Multiparity, COPD, constipation, ascites, and causes of raised intra-abdominal pressure are its other predisposing factors [2].

Arnaud de Ronsil was the first to describe the obturator hernia in 1724 and Obre was the first to perform the successful operation in 1851 [1].

Obturator hernia occurs through obturator canal which is 1 cm wide and 2-3 cm long. The obturator foramen is formed by continuity of pubic and ischial bones and is covered by obturator membrane except in its anterosuperior aspect where it is perforated by obturator nerve, artery, and vein. These travel along 2-3 cm in oblique tunnel (obturator canal) formed by obturator externus and internus muscles. Peritoneal hernia develops through this defect by first increasing separation of muscular band of obturator internus muscle and later separating obturator externus muscle. The hernia sac finally lies on top of obturator externus muscle beneath pectineus muscle.

Clinical diagnosis of obturator hernia is difficult due to uncommon incidence, deep location, and infrequent symptoms and signs. Early diagnosis is needed as delay in its recognition causes poor prognosis in patients. Vast majority of patients fail to complain of obturator neuralgia. Physical examination is not contributory with resultant delay in diagnosis. Hernial sac irritates and compresses obturator nerve within the canal causing medial thigh pain (Howship-Romberg sign). Howship-Romberg sign is pain radiating down the medial aspect of the thigh to the knee and less often to the hip due to compression of the anterior division of the obturator nerve. It is considered pathognomonic of obturator hernia and is seen in up to 15-50% of patients. Palpable mass is found in 20% of cases in the proximal medial aspect of the thigh at the origin of the adductor muscles [1, 3]. High index of suspicion of obturator hernia should be made when an elderly patient presents with small bowel obstruction with intermittent symptoms and medial thigh pain is present.

Early and rapid clinical and appropriate radiological evaluation followed by early surgery is essential for successful treatment. Delay in specific diagnosis causes increased morbidity and mortality as the only treatment available is surgical reduction and repair of hernia. Surgical intervention is delayed due to clinical and radiological diagnostic difficulty.

Early CT imaging causes early diagnosis with reduced morbidity and mortality associated with obturator hernia [4]. X-ray standing abdomen shows evidence of small bowel obstruction in cases of obstructed obturator hernia. USG shows hernia in inguinal and upper femoral region. Often it is misdiagnosed as inguinal or femoral hernia. Signs of small bowel obstruction are seen if it is obstructed and incarcerated. CT scan is diagnostic (Table 2). CT imaging of bowel herniating through the obturator foramen and lying between the pectineus muscle anteriorly and obturator externus muscle posteriorly is diagnostic. This is best demonstrated by low axial CT image in inguinal and upper thigh region. CT can also diagnose asymptomatic bilateral obturator hernia [5].

Various surgical approaches are described in the literature in cases of obstructed obturator hernia. Abdominal, inguinal, retropubic, obturator, and laparoscopic approaches have been described. The published data favors the abdominal approach, utilizing a low midline incision. This method allows the surgeon to establish the diagnosis, avoid obturator vessels, give better exposure of the obturator ring, and facilitate bowel resection if necessary. Herniorrhaphy is performed by simple closure of the hernial defect with interrupted sutures, placement of a synthetic mesh. These have the lowest complication rates. Laparoscopic repair of obturator hernia can also be done. It produces less postoperative pain with shorter hospital stay and fewer pulmonary complications [6, 7].

4. Conclusion

High index of suspicion for obturator hernia should be made in a patient presenting with small bowel obstruction with medial thigh pain. All hernia orifices (inguinal, femoral) should be assessed and screening for Howship-Romberg sign should be done. Early diagnosis can be done by early CT scanning after ruling out inguinal and femoral hernias. This will increase the speed of diagnosis and avoid complications like bowel ischemia.

Useful Tips and Tricks during Examination and Imaging of Obturator Hernia

Clinical Features

(i) Emaciated thin elderly females.

(ii) Intermittent attacks of small bowel obstruction.

(iii) Howship-Romberg sign.

(iv) Referred pain relieved by flexion of thigh and aggravated by extension, abduction, and medial rotation of thigh.

(v) Tender swelling in region of obturator foramen on vaginal and rectal examination.

X-Ray

(i) Small bowel obstruction.

(ii) Gas shadow in obturator foramen area.

USG

(i) Hernia deep to pectineus muscle on axial scan of inguinal region.

(ii) Hernia occurring in plane similar to femoral canal but deep to pubic ramus.

(iii) Small bowel obstruction.

CT

(i) Identification of hernia between pectineus and obturator externus muscles.

(ii) Small bowel obstruction.

http://dx.doi.org/10.1155/2014/625873

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

References

[1] N. Hodgins, K. Cieplucha, P. Conneally, and E. Ghareeb, "Obturator hernia: a case report and review of the literature," International Journal of Surgery Case Reports, vol. 4, no. 10, pp. 889-892, 2013.

[2] L. De Clercq, K. Coenegrachts, T. Feryn et al., "An elderly woman with obstructed obturator hernia: a less common variety of external abdominal hernia," JBR-BTR, vol. 93, no. 6, pp. 302-304, 2010.

[3] Z. Antoniou, E. Volakaki, E. Giannakos, D. C. Kostopoulos, and A. Chalazonitis, "Intestinal obstruction due to an obturator hernia: a case report with a review of the literature," OA Case Reports, vol. 2, no. 1, article 5, 2013.

[4] S. K. Dundamadappa, I. Y. Tsou, and J. S. Goh, "Clinics in diagnostic imaging," Singapore Medical Journal, vol. 47, pp. 88-94, 2006.

[5] D. A. Jamadar, J. A. Jacobson, Y. Morag et al., "Sonography of inguinal region hernias," American Journal of Roentgenology, vol. 187, no. 1, pp. 185-190, 2006.

[6] J.-M. Wu, H.-F. Lin, K.-H. Chen, L.-M. Tseng, and S.-H. Huang, "Laparoscopic preperitoneal mesh repair of incarcerated obturator hernia and contralateral direct inguinal hernia," Journal of Laparoendoscopic and Advanced Surgical Techniques, vol. 16, no. 6, pp. 616-619, 2006.

[7] L. Hunt, C. Morrison, J. Lengyel, and P. Sagar, "Laparoscopic management of an obstructed obturator hernia: should laparoscopic assessment be the default option?" Hernia, vol. 13, no. 3, pp. 313-315, 2009.

Sanjay M. Khaladkar, Anubhav Kamal, Sahil Garg, and Vigyat Kamal

Department of Radio-Diagnosis, Dr. D. Y. Patil Medical College, Pimpri, Pune 411018, India

Correspondence should be addressed to Anubhav Kamal; anubhav.xeno@gmail.com

Received 20 September 2014; Accepted 20 November 2014; Published 3 December 2014

Academic Editor: Paul Sijens

TABLE 1: Hernia types with typical location
and diagnostic imaging findings.

Hernia name          Location

Inguinal direct      Hesselbach's triangle
Inguinal indirect    Hesselbach's triangle
Pantaloon            Hesselbach's triangle
Spigelian            Along linea semilunaris
Paraumbilical        Defect in the linea alba
Femoral              Medial aspect of the
                       femoral canal
De Garengeot         Femoral canal
Amyand               Inguinal canal
Littre               Any location
Richter              Any location, though
                       usually  along anterior
                       abdominal wall
Obturator            Obturator canal through
                       obturator foramen
Grynfeltt-Lesshaft   Upper lumbar triangle
Petit                Lower lumbar triangle

Hernia name          Diagnostic imaging features

Inguinal direct      Medial to the inferior
                       epigastric artery (MD)
Inguinal indirect    Lateral to the inferior
                       epigastric artery (IL)
Pantaloon            Contains both direct and
                       indirect inguinal hernias
Spigelian            At junction of lateral
                       abdominal muscles and
                       rectus sheath
Paraumbilical        Associated with diastasis
                       of the rectus muscles
Femoral              Hernia sac with femoral vein
                       compression
De Garengeot         Contains the appendix
Amyand               Contains the appendix
Littre               Contains Meckel's diverticulum
Richter              Contains only antimesenteric
                       side of a loop of bowel

Obturator            Between pectineus and obturator
                       externus muscles; often
                       presents with incarceration
Grynfeltt-Lesshaft   Location
Petit                Location

TABLE 2: Advantages, limitations, and pitfalls of
diagnostic modalities for abdominal wall hernias.

Modality   Advantages

USG        Availability, portability, low
           cost, and no ionizing radiation

           Capability of real time imaging
           (DASH, dynamic abdominal
           sonography for hernia, in supine
           and upright position at rest and
           with Valsalva's maneuver),
           comparison with unaffected side

           Can diagnose postoperative
           seromas and hematomas and can
           diagnose recurrent hernia along
           edge of repair using Valsalva
           maneuver

MDCT       High spatial and contrast
           resolution and multiplanar
           imaging

           Detection of defect and contents
           of hernia and its complications
           (like incarceration,
           strangulation, bowel ischemia,
           and bowel obstruction)

           Detection of postoperative
           complications-seroma, hematoma

           Differentiation of hernia from
           other abdominal wall masses like
           hematoma, abscess, tumor, and
           undescended testis

           CT performed during postural
           maneuver (prone, lateral
           decubitus position), maneuver to
           increase intra-abdominal pressure
           (straining, Valsalva's maneuver)
           and increase lesion detection

Modality   Limitations                 Pitfalls

USG        Being operator dependent,   Lipoma of spermatic
           need of high frequency      cord and abdominal
           transducer, obesity,        wall
           scarring, and patients
           with acute abdominal pain

           Sonographic evaluation
           after hernia repair may
           be difficult due to dense
           shadowing caused by
           surgical mesh

MDCT       Ionizing radiation,
           pregnant patients, being
           expensive, and
           availability
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Title Annotation:Clinical Study
Author:Khaladkar, Sanjay M.; Kamal, Anubhav; Garg, Sahil; Kamal, Vigyat
Publication:Radiology Research and Practice
Article Type:Report
Date:Jan 1, 2014
Words:2083
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