Strangulated obturator hernia: still deadly

The case of an elderly, emaciated female patient with recurrent lower abdominal and hip pain associated with nausea and vomiting due to an incarcerated obturator hernia is described. The presence of a Howship-Romberg sign and a tender mass on digital rectal examination in this thin, elderly woman with a small bowel obstruction led to the rapid diagnosis of an obturator hernia by computed tomography (CT). The high mortality rate associated with this most lethal of all abdominal hernias requires a high index of suspicion to facilitate rapid diagnosis and surgical intervention if the survival rate is to be improved.     

Appendicitis in an obturator hernia

We present a case of a 79-year-old female with a history of pain at the right groin for 9 days. Computer tomography of the pelvis showed herniation of the appendix through the obturator canal with a huge abscess surrounding the right hip joint. Laparotomy was performed and histopathology confirmed a perforated necrotic tip of the herniated appendix. An obturator hernia is a rare hernia of the pelvic floor. It is most common in old, emaciated, multiparous women and can cause groin pain with extension to the medial aspect of the thigh. In case of incarceration of bowel, patients also present with obstruction. Isolated incarceration of the appendix, however, does not cause obstruction. The diagnosis of an obturator hernia is often delayed, due to a non-specific clinical presentation. CT scan may offer the clue to the correct diagnosis and should be performed in case of a possible obturator hernia.     

Incarcerated obturator hernia treated using a hybrid laparoscopic and anterior preperitoneal approach: A case report

Obturator hernia (OH) is a rare cause of bowel obstruction. Although several surgical approaches, including the laparoscopic approach, have been reported to date, a standard approach for treating OH has not been established. A 101‐year‐old woman who presented with constipation and vomiting was admitted to our hospital. CT revealed an incarcerated small bowel within the left obturator foramen, and a diagnosis of left‐sided incarcerated OH with small bowel ileus was made. With the patient under general anesthesia, exploratory laparoscopy was performed; we identified an OH with an incarcerated small bowel, which was judged viable after hernia reduction. We repaired the hernia using an anterior preperitoneal approach under laparoscopic assistance and placed a prosthetic mesh over the obturator foramen. The patient recovered with no postoperative complications and was discharged on postoperative day 4. A hybrid laparoscopic and anterior preperitoneal approach is safe and effective for treating an incarcerated OH in an elderly patient.     

Strangulated obturator hernia: can mortality be reduced?

We describe two patients with strangulated obturator hernia to enhance clinical awareness of the varied presentations of this uncommon hernia, which occurs especially in elderly women with either recurrent abdominal pain or partial intestinal obstruction, a positive Howship-Romberg sign, and an absent thigh adductor reflex. Early laparotomy for unexplained bowel obstruction is essential to avoid the complications associated with strangulated obturator hernia.     

Computed tomographic diagnosis of obturator foramen hernia

Computed tomography was performed on a patient presenting with cryptic small bowel obstruction. A correct preoperative diagnosis of obturator foramen hernia was arrived at based on the recognition of a loop of ileum protruding between the pectineus and external obturator muscles.     

Preoperative diagnosis of obturator hernia by computed tomography in six patients

Obturator hernia is a rare condition, and the prognosis of patients with this condition is poor. A retrospective study was performed on six patients with obturator hernia between 1993 and 1998. They had been diagnosed preoperatively by computed tomography (CT). The initial CT scan of the abdomen, including the pelvic area, revealed an incarcerated bowel in the obturator foramen of all six patients. All patients underwent laparotomy on the day of admission. Resection of the small bowel was performed in three patients, and release of the small bowel was performed in the remaining three patients. There were no perioperative deaths. In elderly women who have evidence by abdominal plain X-ray studies of small bowel obstruction, we recommend performing CT scan of the abdomen, including CT scan of the pelvic area, for detection of obturator hernia.     

Gangrenous appendicitis in a strangulated obturator hernia

Only two cases of appendicitis in strangulated obturator hernia have been previously reported. In the present case, an 83-year-old woman had fatal anaerobic myonecrosis of the thigh that resulted from gangrenous appendicitis in the right obturator foramen. Early diagnosis, prompt surgical intervention, and perioperative resuscitation are critical for survival in a case of appendicitis in a strangulated obturator hernia with thigh sepsis, especially when it occurs in an elderly, emaciated female patient.     

Obturator hernia: a difficult diagnosis

We have presented the case of an elderly woman with severe kyphoscoliosis, osteoarthritis and left knee effusion who had symptoms and signs of intermittent intestinal obstruction. Operation showed a left-sided obturator hernia. In any elderly, debilitated, chronically ill woman, symptoms and signs of recurrent small-bowel obstruction (without a history of abdominal surgery or external hernias) and pain along the ipsilateral thigh and knee (Howship-Romberg sign) should raise suspicion for an obturator hernia. If the hernia is not palpable by physical examination, a CT scan of the pelvis and upper aspect of the thigh would confirm the diagnosis before operation and allow prompt treatment and better chance of patient survival.     

小肠机械性肠梗阻的CT诊断

目的 探讨小肠机械性肠梗阻病因的CT表现和诊断价值。方法 对53例小肠机械性肠梗阻的CT表现与手术、病理和临床随诊结果对照分析。结果 53例小肠机械性肠梗阻病因中，肠粘连18例，炎症10例，肠肿瘤8例，腹外疝6例，腹内疝3例，异物4例，肠套叠3例，肠扭转1例，CT诊断小肠机械性肠梗阻病因的符合率5％(49／53)。结论 CT对小肠机械性肠梗阻病因有较高的诊断价值。     

Ultrasound‐guided reduction of an incarcerated obturator hernia in an elderly patient

Obturator hernia is a rare but clinically relevant cause of intestinal obstruction, usually found in elderly, thin, multiparous women. It is difficult to diagnose, leading to diagnostic delay with a high incidence of strangulation and a high mortality rate. Surgery is the only reported treatment. We report the case of an 86‐year‐old woman, in whom an early diagnosis of incarcerated obturator hernia was made with subsequent reduction by compression with an ultrasound transducer. When the risk of strangulation is presumed to be low, ultrasound‐guided reduction of an obturator hernia is achievable and worth considering.     

闭孔疝的CT表现

目的 探讨闭孔疝的CT表现，以提高对其疾病的诊断水平。方法回顾性分析2009年10月-2010年9月收治的经手术或临床资料证实的3例闭孔疝患者的CT影像学表现，观察闭孔疝发生的位置、密度、形态、强化特征及继发征象。结果3例闭孔疝均为老年消瘦患者，CT检查发现疝囊位于闭孔外肌与耻骨肌间疝出1例，闭孔外肌上、中束间疝出2例，所有疝出物均为肠管，表现为疝出部位囊性密度影，1例肠壁可见增厚、水肿，诊断为肠壁血运障碍，及时行手术治疗后预后良好。结论CT检查是闭孔疝有效的检测手段，特别是对于不明原因腹痛合并肠梗阻的老年消瘦患者，CT检查将有助于临床确诊。     

Delayed diagnosis of small bowel obstruction following laparoscopic lymph node dissection

Laparoscopic surgical procedures are infrequently complicated by bowel herniation through unsutured trocar sites. Nevertheless, there is a risk of this complication in patients presenting with symptoms of small bowel obstruction after laparoscopy. We present a case of delayed small bowel obstruction due to a Richter's hernia, a rare type of hernia that involves incomplete protrusion of bowel wall through a surgical defect. Knowledge of this potential complication of laparoscopic procedures may prevent the significant morbidity that results from mechanical small bowel obstruction with necrosis.     

腹壁疝的螺旋CT表现及临床应用

目的：探讨螺旋CT对腹壁疝的诊断价值和临床意义。方法：收集被手术证实的腹壁疝86例,术前均进行螺旋CT检查。观察腹壁疝的部位、数目、疝囊大小、疝内容物及并发症。结果：86例腹壁疝中,腹股沟斜疝38例（双侧7例）,腹股沟直疝8例,腹壁切口疝19例,造瘘口疝6例,闭孔疝3例,脐疝8例,白线疝2例,双侧腹股沟斜疝伴右下腹壁切口疝1例,双测腹股沟斜疝伴左下腹壁造瘘口疝1例。疝囊直径在5 cm以下者45例,6-10 cm者38例,10 cm以上者3例,腹壁疝伴小肠不全梗阻者21例,切口疝伴感染1例。螺旋CT可以显示腹壁疝的种类、数目、疝囊大小、疝内容物类型及存在的并发症。结论：螺旋CT是腹壁疝的一种非常有效的检查方法,可以为外科综合评价患者病情及进行有效手术治疗提供重要依据。     

Preoperative diagnosis of obturator hernia by computed tomography

A retrospective study of 6 patients with obturator hernia diagnosed before surgery by X-ray and computed tomography (CT) was conducted between 1993 and 2000. The initial CT of the abdomen including the pelvic area revealed incarcerated bowel in the obturator foramen of all 6 patients. All patients underwent laparotomy as soon as possible after CT scans were obtained. Resection of the small bowel was performed in 3 patients, and release of the small bowel was performed in the remaining 3 patients. There were no perioperative deaths. In elderly women who show evidence of small bowel obstruction by abdominal plain x-ray studies, we recommend performing CT scans of the abdomen including the pelvic area for detection of obturator hernia.     

Intramesosigmoid hernia: preoperative diagnostic MDCT findings

Internal hernias, protrusion of abdominal viscera into an intraperitoneal fossa, are uncommon causes of bowel obstruction, and preoperative diagnoses are difficult. We report a rare case of a 47-year-old female with strangulated small bowel obstruction secondary to an intramesosigmoid hernia preoperative diagnosis by multi-detector row computed tomography. We highlight the preoperatively diagnosed value and findings of MDCT in intramesosigmoid hernia.     

Intestinal blood flow evaluation using the indocyanine green fluorescence imaging method in a case of incarcerated obturator hernia: A case report

In surgery for incarcerated hernia, intestinal blood flow is an important factor in intraoperative decision-making given that irreversible ischemia can result in intestinal necrosis. Here, we report a case of incarcerated obturator hernia in which the bowel was successfully preserved by evaluating intestinal blood flow with the indocyanine green fluorescence imaging method. A woman in her 80s was diagnosed with incarcerated right obturator hernia, and a laparoscopic operation was performed. The small bowel tissue that had been incarcerated exhibited dark red discoloration. Fluorescence examination of the bowel wall indicated that the ischemic changes were reversible, and accordingly, the bowel was not resected. The postoperative course was uneventful. The indocyanine green fluorescence imaging method is a useful new source of evidence that will improve intraoperative decision-making regarding bowel ischemia.     

Right paraduodenal hernia successfully treated with laparoscopic surgery

A 23‐year‐old Japanese man presented with a history of sudden‐onset right abdominal pain accompanied by nausea and vomiting. Contrast‐enhanced CT showed a large cluster on the right side of the retroperitoneum, with most of the small bowel incarcerated. The patient was diagnosed with small bowel obstruction caused by a right paraduodenal hernia, and emergency laparoscopic surgery was performed. The large retroperitoneal cluster on the right side contained almost all segments of the small bowel, although the incarcerated bowel showed no evidence of volvulus or ischemia. The bowel was reduced, and the hernia orifice was closed. The patient made good progress and was discharged 7 days after surgery. We herein report an acute case of right paraduodenal hernia with small bowel obstruction that was successfully treated with emergency laparoscopic surgery. With an early preoperative diagnosis, laparoscopic surgery is appropriate for the treatment of right paraduodenal hernia.     

Right paraduodenal hernia: characteristic MDCT findings

Right paraduodenal hernia is a very rare cause of abdominal pain. It can lead to bowel obstruction, ischemia, and perforation with a high mortality. A timely and correct diagnosis with a rapid diagnostic tool is mandatory. However, clinical diagnosis of right paraduodenal hernia is difficult for its nonspecific symptoms. Traditionally, paraduodenal hernia was diagnosed by small bowel series that was a time-consuming image study. We report a case of right paraduodenal hernia with pre-operative fast diagnosis by multidetector row computed tomography. Fortunately, the ischemic bowel loops were timely alleviated by reduction and resection was prevented.     

Inferior lumbar triangle hernia with incarceration

Lumbar hernia is a rare condition in which intra or extraperitoneal tissue protrudes through a defect in the posterolateral region of the flank. Incarceration is uncommon but represents a surgical emergency when present. A 54-year-old-male presented to the ED after sudden onset left flank pain after coughing. He was in significant distress secondary to pain and vomiting, and his physical exam revealed a tender mass in his left lateral lumbar region near the site of a previous stab wound. Bedside ultrasound revealed a fluid-filled structure, and CT scan demonstrated herniation of small bowel though the inferior lumbar triangle with associated small bowel obstruction. The patient underwent emergent surgical reduction with mesh repair and recovered uneventfully. Incarcerated lumbar hernia represents a rare diagnosis that may not be at the forefront of most practitioners' differential diagnoses. CT scan is useful to distinguish hernia from solid mass, abscess, or other pathology, while bedside ultrasound may prompt an attempt at immediate reduction. The presence of incarcerated bowel or obstruction warrants immediate surgical consultation.     

Ileocecal herniation through the foramen of Winslow: MDCT diagnosis

We report a rare case of small bowel obstruction of a 45-year-old female which was caused by internal hernia of the terminal ileum and cecum through the foramen of Winslow. The patient presented to the emergency department with acute abdominal pain, distention, and nausea, suggesting an intestinal obstruction. The complete unambiguous preoperative diagnosis was achieved by a 64-row multi-detector computed tomography. This report enlightens the utility and performances of high-quality computed tomography multiplanar reconstructions combined with vascular volume rendering analysis for the diagnosis of internal hernia.