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CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 42 (2018) 154–157 Contents lists available at ScienceDirect International Journal of Surgery Case Reports j ourna l h om epage: www.casereports.com Bowel obstruction in obturator hernia: A challenging diagnosis L. Conti a,∗ , E. Baldini a , P. Capelli a , C. Capelli b a Department of General, Vascular and Breast Surgery, G. Da Saliceto Hospital, Cantone del Cristo 50, Piacenza, Italy b Faculty of Medicine, University of Milan, Via Festa del Perdono 7, Milano, Italy a r t i c l e i n f o Article history: Received 24 October 2017 Received in revised form 29 November 2017 Accepted 2 December 2017 Available online 7 December 2017 a b s t r a c t INTRODUCTION: The obturator hernia is a rare pelvic hernia that often comes in the shape of bowel obstruction caused by the presence of an intestinal segment, more often ileum, passing trough the obturator foramen of the pelvic wall (Fig. 1). This type of hernia accounts for 0.5-1.4% of all hernias. CASE PRESENTATION: We report the clinical case of a 84-year-old woman with no previous surgical inter- ventions, who went to the emergency room complaining of vomit and nausea, bowels closed to gas and stool, which she had experienced for three previous days. Routine blood test showed impaired renal func- tion and hydrohelectrolyte imbalance. A CT scan revealed a right ileal, strangulated obturator hernia. The patient underwent an emergency surgical intervention with laparoscopic trans-abdominal peritoneal approach (TAP): after the reduction of the herniated segment, a primary suturing of the parietal defect was performed without ileal resection. DISCUSSION: Because of the non-specific symptoms the diagnosis of this kind of hernia is often unclear; female are 6–9 times more likely than men to be subject to the aforementioned pathology, mostly occur- ring in multiparous, emaciated, elderly woman so it is also called “the little old lady’s hernia”. Risk factors are loss of weight, chronic pulmonary disease and ascites which increase the abdominal pressure. An unfrequent presenting sign is a palpable mass, or the Howship-Romberg sign- a pain radiating from the inner tigh and knee − but it could be misleading when confused with symptoms of gonarthrosis or lumbar vertebral disc pathology. CT scan has superior sensitivity and accuracy with respect to other radiological exams to assess the presence of an obturator hernia. CONCLUSION: Obturator hernia is a rare type of hernia due to his diagnosis, which is often unclear; a prompt suspect based for the non-specific symptoms is crucial for the diagnosis. Surgical management depends on early diagnosis and it is the only possible treatment for this pathology. © 2017 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction This work has been reported in line with the SCARE criteria [3]. Obturator hernia is a rare pelvic hernia, accounting for the 0.5–1.4% of all hernias [4] that frequently causes bowel obstruc- tion (Fig. 1); it is observed in elderly emaciated and multiparous women, so it’s also called “little old’s lady hernia” [5]. The hernia sac usually contains small bowel, rarely appendix, colon, Meckel diverticulum or omentum [6]. A prompt diagnosis and treatment could avoid complications such as necrosis of intestine which increases morbidity and mortality. ∗ Corresponding author. E-mail addresses: [email protected] (L. Conti), [email protected] (E. Baldini), [email protected] (P. Capelli), [email protected] (C. Capelli). 2. Presentation of case An 84-years-old, emaciated woman was brought to the emer- gency department of our hospital complaining of abdominal pain, nausea and vomit which she had experienced for three previous days. The patient appeared to be debilitated and scrawny. The physical exam revealed a palpable thyroid goiter. The patient was afebrile, tachycardic, with a blood pressure of 115/60; the abdominal exam was negative, faint borborygmis were audible, no palpable mass was detected and there were no feces on the rectal digital explo- ration. Blood routine test revealed an increase value of creatinine, which was a new finding, low serum sodium and chlorine and raised levels of inflammatory values. A chest and abdomen X-ray revealed air-fluid level in the mesogastric region and no pulmonary lesions were observed. An abdominal ultrasound showed the gall- bladder filled with biliary sludge with no pathological findings. A nasogastric tube and a urinary catheter were placed. The patient https://doi.org/10.1016/j.ijscr.2017.12.003 2210-2612/© 2017 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

AUSL - International Journal of Surgery Case Reports...CASE REPORT – OPEN ACCESS L. Conti et al. / International Journal of Surgery Case Reports 42 (2018) 154–157 155 Fig. 1. Anatomy

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    CASE REPORT – OPEN ACCESSInternational Journal of Surgery Case Reports 42 (2018) 154–157

    Contents lists available at ScienceDirect

    International Journal of Surgery Case Reports

    j ourna l h om epage: www.caserepor ts .com

    owel obstruction in obturator hernia: A challenging diagnosis

    . Conti a,∗, E. Baldini a, P. Capelli a, C. Capelli b

    Department of General, Vascular and Breast Surgery, G. Da Saliceto Hospital, Cantone del Cristo 50, Piacenza, ItalyFaculty of Medicine, University of Milan, Via Festa del Perdono 7, Milano, Italy

    r t i c l e i n f o

    rticle history:eceived 24 October 2017eceived in revised form9 November 2017ccepted 2 December 2017vailable online 7 December 2017

    a b s t r a c t

    INTRODUCTION: The obturator hernia is a rare pelvic hernia that often comes in the shape of bowelobstruction caused by the presence of an intestinal segment, more often ileum, passing trough theobturator foramen of the pelvic wall (Fig. 1). This type of hernia accounts for 0.5-1.4% of all hernias.CASE PRESENTATION: We report the clinical case of a 84-year-old woman with no previous surgical inter-ventions, who went to the emergency room complaining of vomit and nausea, bowels closed to gas andstool, which she had experienced for three previous days. Routine blood test showed impaired renal func-tion and hydrohelectrolyte imbalance. A CT scan revealed a right ileal, strangulated obturator hernia. Thepatient underwent an emergency surgical intervention with laparoscopic trans-abdominal peritonealapproach (TAP): after the reduction of the herniated segment, a primary suturing of the parietal defectwas performed without ileal resection.DISCUSSION: Because of the non-specific symptoms the diagnosis of this kind of hernia is often unclear;female are 6–9 times more likely than men to be subject to the aforementioned pathology, mostly occur-ring in multiparous, emaciated, elderly woman so it is also called “the little old lady’s hernia”. Riskfactors are loss of weight, chronic pulmonary disease and ascites which increase the abdominal pressure.An unfrequent presenting sign is a palpable mass, or the Howship-Romberg sign- a pain radiating fromthe inner tigh and knee − but it could be misleading when confused with symptoms of gonarthrosis

    or lumbar vertebral disc pathology. CT scan has superior sensitivity and accuracy with respect to otherradiological exams to assess the presence of an obturator hernia.CONCLUSION: Obturator hernia is a rare type of hernia due to his diagnosis, which is often unclear; aprompt suspect based for the non-specific symptoms is crucial for the diagnosis. Surgical managementdepends on early diagnosis and it is the only possible treatment for this pathology.

    © 2017 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an openhe CC

    access article under t

    . Introduction

    This work has been reported in line with the SCARE criteria [3].Obturator hernia is a rare pelvic hernia, accounting for the

    .5–1.4% of all hernias [4] that frequently causes bowel obstruc-ion (Fig. 1); it is observed in elderly emaciated and multiparousomen, so it’s also called “little old’s lady hernia” [5]. The hernia

    ac usually contains small bowel, rarely appendix, colon, Meckeliverticulum or omentum [6].

    A prompt diagnosis and treatment could avoid complicationsuch as necrosis of intestine which increases morbidity andortality.

    ∗ Corresponding author.E-mail addresses: [email protected] (L. Conti), [email protected]

    E. Baldini), [email protected] (P. Capelli), [email protected]. Capelli).

    ttps://doi.org/10.1016/j.ijscr.2017.12.003210-2612/© 2017 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Greativecommons.org/licenses/by-nc-nd/4.0/).

    BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

    2. Presentation of case

    An 84-years-old, emaciated woman was brought to the emer-gency department of our hospital complaining of abdominal pain,nausea and vomit which she had experienced for three previousdays.

    The patient appeared to be debilitated and scrawny. The physicalexam revealed a palpable thyroid goiter. The patient was afebrile,tachycardic, with a blood pressure of 115/60; the abdominal examwas negative, faint borborygmis were audible, no palpable masswas detected and there were no feces on the rectal digital explo-ration.

    Blood routine test revealed an increase value of creatinine,which was a new finding, low serum sodium and chlorine andraised levels of inflammatory values. A chest and abdomen X-rayrevealed air-fluid level in the mesogastric region and no pulmonarylesions were observed. An abdominal ultrasound showed the gall-

    bladder filled with biliary sludge with no pathological findings. Anasogastric tube and a urinary catheter were placed. The patient

    roup Ltd. This is an open access article under the CC BY-NC-ND license (http://

    https://doi.org/10.1016/j.ijscr.2017.12.003http://www.sciencedirect.com/science/journal/22102612http://www.casereports.comhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.ijscr.2017.12.003&domain=pdfhttp://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/mailto:[email protected]:[email protected]:[email protected]:[email protected]://doi.org/10.1016/j.ijscr.2017.12.003http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/

  • CASE REPORT – OPEN ACCESSL. Conti et al. / International Journal of Surgery Case Reports 42 (2018) 154–157 155

    of th

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    attocsT

    Fig. 1. Anatomy and limits

    as referred to the nephrology unit with a diagnosis of an acutere-renal failure.

    After rehydratation with saline solutions and total parenteralutrition, the blood values of the patient ranged to normality, the4 h/volume of urine increased .

    As days passed the patient still complained of nausea, vomit andbdominal pain with bowel closed to gas and stool and the nasogas-ric tube draining 500 mL of fecaloid fluid daily. Her abdomen wasender, bloated and tympanic to palpation and percussion, an X-rayf the abdomen demonstrated air-fluid levels. Based on the suspi-

    ion of an acute bowel obstruction, a CT scan was the best applicableolution, without using contrast agent due to low renal excretion.he scan revealed a small intestine segment strangulated through

    Fig 2. CT scan, sagittal section

    e right obturator foramen.

    the obturator right foramen (Fig. 2) with surrounding peritonealfree fluid.

    The patient was transferred to the operating room and under-went to a laparoscopic emergency intervention: the exploration ofthe peritoneal cavity confirmed the radiological diagnosis of bowelobstruction due to a strangulated loop of small intestine enteringthe right obturator foramen (Fig. 3). A primary suture of the pari-etal defect was performed using non-absorbable 2/0 ticron (Fig. 4),no ileal resection was performed because of the vital aspect of theintestine.

    The patient started oral feeding and passed stool on the thirdpost-operative day; discharge was on fourth post-operative dayafter a complete restoration of the bowel function.

    : right obturator hernia.

  • CASE REPORT – OPEN ACCESS156 L. Conti et al. / International Journal of Surgery Case Reports 42 (2018) 154–157

    Fig. 3. Small intestine embedded in right obturator foramen.

    re of

    latw

    3

    lStiawe

    Fig 4. Primary sutu

    The patient was referred to our surgical day hospital for a fol-ow up: she didn’t experienced abdominal tenderness and bloatingnymore, her blood values were normalized and so her renal func-ion, she passed stool each two or three days at least, surgical scarsere consolidated with no signs of infection.

    . Discussion

    Due to the peculiarities of this type of hernia, different prob-ems have arisen while conducting the diagnosis of the pathology.ymptoms such as the pain radiating from the inner parts of thehigh, the knee or the hip could be confused with the dorso-lumbar

    ntervertrebral disc pathology. Signs such as Howship-Rombergnd Hannington-Kiff are aspecific and they should be associatedith a CT scan which is clearly the best performable radiological

    xam [1,2].

    the parietal defect.

    Different surgical approaches are proposed: laparoscopicsurgery, both TAPP −transabdominal- or TEP −total extraperitoneal[7], is feasible in expert settings, but in an emergency set-up usuallya midline incision by laparotomy is required to allow a wider expo-sure of the obturator ring, the pelvic floor and the lower abdomen,especially in the case of gangrenous bowel resection. Other possi-ble approaches can be performed via transinguinal, retropubic orfemoral [8].

    The obturator stump could be repaired using a primary suturewhich has an acceptable recurrence rate lower than 3% [9], a reab-sorbable mesh, a plug or a peritoneal and omentum patch [6].

    4. Conclusion

    Obturator hernia is a rare entity so its diagnosis is often unclear;a prompt suspect based on aspecific symptoms is crucial for thediagnosis. CT scan has a major sensitivity than other radiological

  • – Of Surg

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    CASE REPORTL. Conti et al. / International Journal o

    xams. Surgical management depends on early diagnosis and it ishe only possible treatment for this pathology [5].

    onflicts of interest

    All authors have no conflicts of interest.

    unding

    No sources of funding involved in this case report.

    thical approval

    I declare that ethical approval has been exempted by my Insti-ution for this case Report.

    onsent

    Authors obtained the written and signed consent to publish thease report.

    uthor contributions

    All authors contributed to literature review and interpretationor this case report; first author wrote the case report.

    egistration of research studies

    No unique identifying number requested for this case report.

    pen Accesshis article is published Open Access at sciencedirect.com. It is distribermits unrestricted non commercial use, distribution, and reproductredited.

    PEN ACCESSery Case Reports 42 (2018) 154–157 157

    Guarantor

    LUIGI CONTI, MD.

    References

    1] Y. Yokoyama, A. Yamaguchi, M. Isogai, A. Hori, Y. Kaneoka, Thirty-six cases ofobturator hernia: does computed tomography contribute to postoperativeoutcome? World J. Surg. 23 (2) (1999) 214–217.

    2] R. Terado, S. Ito, H. Kidogawa, H. Kidogawa, K. Kashima, H. Ooe, Obturatorhernia: the usefulness of emergent computed tomography for early diagnosis,J. Emerg. Med. 17 (5) (1999) 883–886.

    3] R.A. Agha, A.J. Fowler, A. Saetta, I. Barai, S. Rajmohan, Orgill DP, for the SCAREgroup. the SCARE statement: consensus-based surgical case report guidelines,Int. J. Surg. (2016).

    4] S.S. Chang, Y.S. Shan, Y.J. Lin, Y.S. Tai, P.W. Lin, A review of obturator her- niaand a proposed algorithm for its diagnosis and treatment, World J. Surg. 29(2005) 450–454.

    5] K.J. Bjork, P. Mucha Jr., D.R. Calull, Obturator hernia, Surg. Gynecol. Obstet. 167(3) (1988) 217–222.

    6] S.K. Mantoo, K. Mak, T.J. Tan, Obturator hernia: diagnosis and treatment in themodern era, Singapore Med. J. 50 (9) (2009) 866–870.

    7] K. Shapiro, S. Patel, C. Choy, G. Chaudry, S. Khalil, G. Ferzli, Totallyextraperitoneal repair of obturator hernia, Surg. Endosc. 18 (6) (2004) 954–956.

    8] C.R. Dorai Thambi, Obturator hernia—Review of three cases, Singapore Med. J.29 (2) (1988) 179–181.

    9] R. Pandey, A. Maqbool, N. Jayachandran, Obturator hernia: a diagnosticchallenge, Hernia 13 (2009) 97–99.

    uted under the IJSCR Supplemental terms and conditions, whichion in any medium, provided the original authors and source are

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    Bowel obstruction in obturator hernia: A challenging diagnosis1 Introduction2 Presentation of case3 Discussion4 ConclusionConflicts of interestFundingEthical approvalConsentAuthor contributionsRegistration of research studiesGuarantorReferences


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