Obturator hernia as a cause of chronic pain after inguinal hernioplasty: elective management using tomography and ambulatory total extraperitoneal laparoscopy

Obturator hernia is a rare variety of pelvic hernia. Preoperative diagnosis is still uncommon and influences treatment and prognosis. Clinical suspicion and tomography are fundamental for establishing a preoperative diagnosis. Subsequently, elective treatment via the total extraperitoneal laparoscopic approach seems to offer the best results for both the patient and the hospital. This management might reduce the high rates of associated morbidity and mortality. We present the case of a patient with chronic pelvic pain after hernia surgery in whom tomography confirmed the existence of a bilateral obturator hernia. Details are given of diagnostic and therapeutic management using ambulatory total extraperitoneal laparoscopy. We recommend ruling out obturator hernia as a possible cause of chronic pain after hernia repair.     

闭孔疝临床诊疗分析：附5例报告

背景与目的 闭孔疝是临床罕见的腹外疝,具有术前诊断率低,病死率高的临床特点。本文通过回顾收治的闭孔疝病例,分析总结闭孔疝的病因、临床特点及诊治方法,以期为该病的诊治提供参考。方法 回顾性分析2011年1月—2021年1月期间收治广东医科大学附属医院5例闭孔疝患者临床资料。结果 5例闭孔疝病例中（4例患者,1例女性患者半年内先后被诊断为左、右侧闭孔疝）,男1例,女4例;年龄61~87岁;除1例术前诊断右侧腹股沟斜疝术中发现同侧隐匿闭孔疝外,其余均以急性机械性肠梗阻首诊;左侧闭孔疝例3例、右侧闭孔疝2例;3例术前行盆腔CT检查并诊断闭孔疝,2例术中明确。1例择期手术外,其余4例均行急诊手术探查。合并小肠嵌顿4例,1例因嵌顿缺血坏死予以小肠切除,其余3例肠管麻醉状态下自行回纳或腹腔镜下协助回纳。修补方式方面,2例用3-0 Prolene行闭孔管口直接缝合关闭,1例行开放式无张力修补,其余2例腹腔镜下腹膜外间隙补片无张力修补。1例患者因并发感染性休克术后第2天ICU死亡,其余4例病例（3例患者）治愈出院。治愈出院患者均获随访,随访时间为1~5年,中位数（3.0±2.2）年,随访无复发。结论 老年女性患者出现病因不明的急性机械性肠梗阻时应考虑闭孔疝可能,盆腹腔CT检查有助于明确诊断。明确诊断后尽早手术,患者条件允许建议腹腔镜探查并修补。     

Obturator Hernia: Laparoscopic Diagnosis and Repair

Objective:

Review of international literature reveals eight reported cases of laparoscopic obturator hernia repair. Non-specific signs and symptoms make the diagnosis of an obturator hernia difficult. Laparoscopic intervention provides a minimally invasive method to simultaneously diagnose and repair these hernias.

Methods and Procedures:

A 35 year old woman presented with lower abdominal pain, vaginal bleeding, and dyspareunia. During gynecological diagnostic laparoscopy, a pelvic floor hernia was suspected, and a general surgical evaluation was sought. At a subsequent laparoscopy, the diagnosis of a left direct inguinal and a right obturator hernia was made. Both were repaired laparoscopically with polypropylene mesh.

Results:

At follow-up at one and six weeks postoperatively, the patient''s complaints of pain had completely resolved.

Conclusion:

The diagnosis of obturator hernia is problematic. The usual presenting signs and symptoms are non-specific. Without conclusive historical or physical findings, laparoscopy is an excellent method for diagnosing obturator hernia. This entity, once diagnosed laparoscopically, can be repaired simultaneously via laparoscopic mesh technique.     

Laparoscopic management of an obstructed obturator hernia: should laparoscopic assessment be the default option?

An obturator hernia is a rare diagnosis that is frequently missed. Patients present with few clinical signs to identify the cause, apart from symptoms of intestinal obstruction. Therefore, obturator hernias are often diagnosed at exploratory laparotomy. The use of computed tomography (CT) has increased the chance of definitive preoperative diagnosis. However, despite these advances, patients who present acutely will frequently undergo an open procedure rather than laparoscopy. We present a case of an acute obstructed obturator hernia diagnosed in a 62-year-old female that was successfully managed laparoscopically.     

闭孔疝的诊断和治疗体会

目的对闭孔疝的病因、诊断、治疗和预后进行总结和讨论。 方法回顾性分析2013年1月至2018年1月,复旦大学附属华东医院普外科疝和腹壁外科治疗与培训中心收治的9例闭孔疝患者的相关临床资料。 结果8例患者术前行腹盆腔CT,7例提示闭孔疝形成伴小肠嵌顿,1例未提示闭孔疝。所有患者均行手术治疗,8例行急诊手术治疗,1例非手术治疗3 d后予手术治疗。其中5例行传统剖腹探查手术,余4例行经腹股沟切口腹膜外入路手术,并行腹腔探查。所有患者均在术中明确闭孔疝,病变位于左侧4例,右侧4例,双侧1例。回纳疝内容物后,行小肠修补3例,1例因嵌顿小肠缺血坏死予以切除。修补方式中,1例行直接缝合,8例行补片修补,其中4例植入生物补片,4例植入合成补片。手术时间40～120 min,平均77.8 min。术后8例患者治愈出院,1例因感染性休克死亡。住院时间4～19 d,平均10.7 d。出院患者术后均随访,随访时间3个月至3年,中位数1.5年,随访期间患者均无闭孔疝复发。 结论对有体型消瘦、多次生育史的老年女性患者,如出现不明原因的小肠梗阻症状,应考虑闭孔疝可能,进行积极的诊治,行腹盆腔多层螺旋CT检查可作为诊断的标准方法。一旦明确诊断,应尽早行积极的手术治疗,术中应注意有无合并疝和对侧隐匿疝的探查。为防止复发,若无禁忌证,使用补片修补较为恰当。     

Impacted obturator hernia treated successfully with a Kugel repair: Report of two cases

Obturator hernia repair has traditionally been performed via an intra-abdominal approach, although laparoscopy is also emerging as a feasible alternative. On the other hand, the Kugel method is a minimally invasive and effective form of repair of groin hernia, but there have been few reports on its use for an incarcerated obturator hernia. We describe how we used the Kugel method to repair an obturator hernia in two patients. Both patients presented with acute intestinal obstruction, necessitating emergency surgery. Via a preperitoneal approach, the impacted obturator hernia was carefully released and the obturator canal defect was repaired with a Kugel patch. One patient recommenced oral intake on postoperative day (POD) 1, and was discharged on POD 5. The other patient’s postoperative course was complicated by ileus, prolonging the hospital stay to 14 days. There has been no sign of recurrent disease for 6 and 21 months, respectively. The Kugel method offers several advantages, such as a short operative time (76–82 min), small scar (3 cm), and early postoperative ambulation (POD 1), thus minimizing the hospital stay. Further study is needed to confirm the usefulness of this procedure for an incarcerated obturator hernia.     

Computed tomographic diagnosis of obturator hernia and its surgical management: a case series

The obturator hernia is a rare type of hernia which usually presents in thin, elderly women. The preoperative diagnosis is typically difficult, with non-specific signs and symptoms which result in a delay in the diagnosis. It can also be an incidental finding at exploratory laparotomy for a patient with intestinal obstruction. The treatment is surgical. A series of four females with obturator hernia is presented. All patients presented with a history of intestinal obstruction and the hernia was diagnosed preoperatively by computed tomography. All patients underwent a preperitoneal mesh repair with a favourable outcome. The diagnosis and the surgical approach are discussed.     

Obturator hernia revisited: surgical anatomy, embryology, diagnosis, and technique of repair

Obturator hernia is the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator canal. The first case was published by de Ronsil in 1724. Obturator hernia is more common in older malnourished women due to loss of supporting connective tissue and the wider female pelvis. The hernia sac usually contains small bowel, especially ileum. It may follow the anterior or posterior division of the obturator nerve. In most cases, obturator hernia presents with intestinal obstruction of unknown cause. It may present with obturator neuralgia, as a palpable mass or, in cases of bowel necrosis, as ecchymosis of the thigh. A correct diagnosis is made in 20 to 30 per cent of cases. CT scan is considered the gold standard for diagnosis, whereas ultrasonography, contrast studies, herniography and plain films are less specific. Surgery is the only treatment option for obturator hernia. Hesitancy to intervene surgically for chronically ill patients results in high mortality. Transabdominal approach is indicated in cases of complete bowel obstruction or suspected peritonitis. The extra-abdominal approach is used in preoperatively diagnosed cases and in absence of bowel strangulation. The laparoscopic approach is minimally invasive and effectively reduces morbidity. The defect is closed using sutures, tissue flaps, or prosthetic mesh.     

Obturator hernia: embryology, anatomy, surgery

Summary Obturator hernia is relatively rare and typically affects frail, elderly, multiparous women. Most obturator hernias contain small intestine, usually a knuckle of ileum; obstruction is often partial. A history of previous episodes of acute obstruction followed by remission is common. Strangulation eventually occurs, and surgical intervention is the only effective treatment. Pain in the medial aspect of the thigh, sometimes radiating to hip and knee joints (Howship-Romberg sign), and loss of the adductor reflex of the thigh in the presence of positive patellar reflex (Hannington-Kiff sign) are the only distinguishing symptoms. They are not always present or, if present, may be overlooked. For all practical purposes, the hernia through the obturator canal is never externally visible and a palpable mass is detected only occasionally. Thus, it is not suspected and was formerly rarely diagnosed before exploratory laparotomy. Intestinal obstruction of unknown origin was the usual preoperative diagnosis. More recently, however, with ultrasonography, I CT scan, and laparoscopy, diagnosis has improved, paving the way for a decline in morbidity and mortality. We believe an abdominal approach is the treatment of choice (lower suprapubic transverse or lower midline incision).     

Laparoscopic repair of obturator hernia

Management of patients presenting with bowel obstruction secondary to oburator hernia is difficult due to the rarity of the condition. Herein, two patients with incarcerated obturator hernia are presented, and the role of diagnostic laparoscopy in their management is discussed. A new surgical approach, transabdominal repair with dual mesh, is described.     

Laparoscopic transabdominal preperitoneal hernioplasty of bilateral obturator hernia

Obturator hernia is relatively rare and tends to occur in elderly, emaciated women with chronic diseases. Clinical presentations are frequently delayed and so preoperative diagnosis is difficult. Treatment is always surgical. We present a case of a 75-year-old woman with bilateral obturator hernia diagnosed by the physical examination and abdominopelvic computed tomography (CT) scan; she had no signs of bowel strangulation. We used a laparoscopic approach for correction. A transabdominal preperitoneal hernioplasty was done using a prosthetic patch of polypropylene mesh. The patient recovered very well after surgery. We suggest that a laparoscopic approach may be used as treatment, when a nonstrangulated obturator hernia is diagnosed preoperatively.     

闭孔疝的诊断和治疗

目的探讨闭孔疝的诊治方法。方法对15例闭孔疝病例诊治经过结合相关文献进行回顾性分析。结果15例中,术前确诊率仅20%(3/15),误诊率80%(12/15),全组均行疝环修补术,采用剖腹探查切口。本组治愈率100%,术后切口感染及愈合不良4例(21.67%),随访8例至今无复发。结论术前易误诊、漏诊;对年老体弱、多胎生育伴有不明原因肠梗阻表现的妇女,应高度考虑闭孔疝,Howship-Romberg征及Hannington-Kiff征阳性可确诊。疝环修补术是惟一有效的方法,首选腹腔内入路。早确诊,及时手术是减少并发症、降低死亡率的关键。     

A Review of Obturator Hernia and a Proposed Algorithm for its Diagnosis and Treatment

The aim of this article is to provide a review of six patients with the various stages of obturator hernia and a diagnostic and therapeutic strategy in suspected cases. Obturator hernia is relatively rare and is a diagnostic challenge. It is a significant cause of intestinal obstruction, especially in emaciated elderly women with chronic disease. A palpable groin mass is not common in these patients because the hernia mass is usually concealed beneath the pectineus muscle. The high mortality is directly related to the delayed recognition, with resultant ruptured gangrenous bowel, and to the high incidence of patients with concurrent medical illness. A total of six patients with obturator hernias were treated at this hospital between 1994 and 2004, and one of these patients was diagnosed and treated by elective laparoscopy. We reviewed these six cases and examined the clinical presentation, age, body weight, associated medical conditions, preoperative diagnosis, operative findings, complications, and outcome in this retrospective study. We concluded that we cannot shorten the time from onset of symptoms to admission, but what we can do is to make a rapid evaluation and surgical intervention to reduce the morbidity and mortality from obturator hernia. The approaches to different presentation of obturator hernia and diagnostic role of CT scan are also discussed.     

闭孔疝早期诊断和外科治疗

目的探讨闭孔疝的早期诊断,以及开放式全腹膜外疝修补术在闭孔疝治疗中的应用。方法回顾性分析2000年1月至2013年6月,浙江大学医学院附属第二医院收治的4例闭孔疝患者的临床资料,分析、讨论其病例特点。结果4例闭孔疝患者,术前皆行CT检查,明确闭孔疝诊断。其中3例因肠梗阻急诊人院,并急诊行剖腹探查术,术中发现肠管坏死而行肠切除,单纯修补闭孔缺损;另1例患者,因左下肢痛入院,择期行开放式全腹膜外疝修补术,术后恢复良好。结论对于能早期诊断的闭孔疝患者,开放式全腹膜外疝修补术是一种安全、有效的手术方法。     

择期闭孔疝的临床特征分析及治疗方法探讨

目的分析择期闭孔疝的临床特征并探讨其治疗方法。 方法回顾性分析2013年8月至2018年8月,四川大学华西医院收治的11例择期行无张力闭孔疝修补患者的临床资料。分析其临床特征,探讨手术治疗方法,记录术后并发症发生及复发情况。 结果11例患者均为女性,确诊为闭孔疝,病程2个月至14年,平均体质量指数（17.62±2.16）kg/m²,平均年龄（76.63±9.15）岁,合并心肺疾病4例。均有反复下腹痛。术前诊断为双侧闭孔疝4例;术前诊断为单侧闭孔疝,术中探查后证实为双侧闭孔疝6例;1例术前及术中证实为单侧,仅行右侧闭孔疝无张力修补,半年后出现新发左侧闭孔疝。所有患者术后随访无闭孔疝复发,无再腹痛,无肠梗阻及腹股沟区慢性疼痛,无大腿及膝部放射性疼痛。所有患者术后切口均无感染。 结论择期闭孔疝常见于高龄消瘦女性,病程长,往往并发心肺基础疾病,临床表现反复下腹疼痛,通常不伴肠梗阻,腹部CT对诊断有重要价值。临床上误诊率高,通常是双侧并发,采用无张力修补复发率低,并发症少,可供借鉴。     

闭孔疝八例诊治体会

目的探讨闭孔疝的临床诊治体会及经验交流。 方法收集2015年1月至2017年12月华中科技大学同济医学院附属同济医院收治的且术中证实为闭孔疝的8例患者临床资料,分析其诊疗过程及临床表现,总结诊疗经验。 结果8例患者均行手术治疗,术后均无并发症,安全出院。 结论闭孔疝临床较少见,临床表现无特异性,术前行多排CT检查,有助于明确诊断。急诊手术治疗为其首选治疗方式,手术预后较好。     

Elective plug repair of an incarcerated obturator hernia by the thigh approach after noninvasive manual reduction: Report of two cases

An obturator hernia is a rare type of pelvic hernia, which can cause bowel obstruction. Despite improved imaging techniques, which can allow us to make a preoperative diagnosis, emergency laparotomy is still often carried out. We repaired this hernia electively in two elderly women by inserting a plug into the obturator canal via the thigh, after noninvasive manual reduction. Both patients were brought to our Emergency Department after the sudden onset of severe pain in the thigh or groin. The diagnosis was confirmed by computed tomography, and manual reduction was performed immediately thereafter. Since both patients had undergone groin hernia surgery of the identical side before, less-invasive inguinal or extraperitoneal approaches were considered impossible, but laparotomy seemed too invasive. Despite being an unfamiliar field for general surgeons, the thigh approach gives excellent and easy access to the obturator canal. The technique we describe is especially useful for patients who have undergone previous groin hernia operations. We expect that this method will become a standard technique for obturator hernias without strangulation.     

Rare case of incarcerated obturator hernia: Case report and review of literature

IntroductionObturator hernia is a rare condition accounting for less than 1% of all intra abdominal hernias. Clinical diagnosis is considered a challenge for most surgeons. It usually appears as an intestinal obstruction. Confirmation of diagnosis is carried out by means of imaging or during surgery.Case reportAn 85-year-old female patient, with symptoms of intestinal obstruction of 24 h duration was admitted to the emergency room of Unimed Hospital – Belo Horizonte. Abdominal computed tomography (CT) demonstrated a herniation of the small bowel through the right obturator canal with an intestinal distension proximally. At laparotomy, the presence of a right obturator hernia with an ileal strangulation was confirmed. Segmental enterectomy with primary anastomosis and herniorrhaphy for the closure of the obturator foramen were performed.DiscussionObturator hernias typically affect women, elderly, emaciated and multiparous. Symptoms are non-specific and associated with an intestinal obstruction. Howship-Romberg sign, considered pathognomonic, is generally absent. Abdominal CT scan can aid in pre-operative diagnosis and the treatment is surgical.ConclusionEarly diagnosis and surgical treatment are imperative in obturator hernias due to the high morbidity and mortality that occur in cases where the intervention is delayed.     

Obturator hernia: A case report and review of the literature

INTRODUCTIONAn obturator hernia is a rare condition but is associated with the highest mortality of all abdominal wall hernias. Early surgical intervention is often hindered by clinical and radiological diagnostic difficulty. The following case report highlights these diagnostic difficulties, and reviews the current literature on management of such cases.PRESENTATION OF CASEWe present the case of an 86-year-old lady who presented with intermittent small bowel obstruction, clear hernial orifices, and right medial thigh pain. Pre-operative CT imaging was suggestive of an obstructed right femoral hernia. However, intra-operatively the femoral canal was clear and an obstructed hernia was found passing through the obturator foramen lying between the pectineus and obturator muscles in the obturator canal.DISCUSSIONObturator hernias are notorious for diagnostic difficulty. Patients often present with intermittent bowel obstruction symptoms due to a high proportion exhibiting Richter's herniation of the bowel. Hernial sacs can irritate the obturator nerve within the canal, manifesting as medial thigh pain, and often no hernial masses can be detected on clinical examination. Increasing speed of diagnosis through early CT imaging has been shown to reduce the morbidity and mortality associated with obturator hernias. However, over-reliance on CT findings should be cautioned, as imaging and operative findings may not always correlate.CONCLUSIONA high suspicion for obturator hernia should be maintained when assessing a patient presenting with bowel obstruction particularly where intermittent symptoms or medial thigh pain are present. Rapid clinical and appropriate radiological assessment, followed by early surgery is critical to successful treatment.     

Obturator Hernia

A report is presented of four cases of obturator hernia treated in Singapore from 1959 to 1969. The literature is reviewed. Important aspects of the clinical presentation, diagnosis and treatment of obturator hernia are stressed, and an important physical sign is observed and described.