Rare cause of intestinal obstruction: A case of obturator hernia in an old age female

INTRODUCTION

An obturator hernia is a form of pelvic hernia in which the contents of the abdomen protrude through the obturator canal.^1,2 It is an uncommon pelvic hernia among all abdominal hernias. Undernourished, thin, elderly females with a history of multiple childbirths are at risk of developing it.³ Preoperative diagnosis of an obturator hernia is difficult, as there is a vague clinical presentation. The majority of obturator hernia cases in our country are diagnosed during operations.⁴ The best diagnostic test for an obturator hernia is Contrast enhanced computed tomography (CECT) abdomen with pelvis.^5,6 Early exploratory laparotomy is necessary due to the significant morbidity and mortality caused by missing or delayed diagnosis.

CASE REPORT

TAn 80-year-old woman complained of lower abdomen pain and left thigh ache for five days when she came to the surgical emergency room. The abdominal distention, bilious vomiting, and three days of non-passage of stool and flatus were all accompanied by the gradually developing discomfort. Multiparous, h/o 5 Term normal vaginal delivery. And H/o open tubal ligation (TL) 55 years ago. On general and physical examination, a malnourished woman had a Body mass index (BMI) of 17.8. Abdominal examination revealed generalized distention with tenderness in the left iliac fossa, and bowel sounds were hyperperistaltic. On digital rectal examination, stool pellets were present.

Imaging

X-ray abdomen- Multiple small air-fluid levels [Figure 1].

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Figure 1: Plain X-ray abdomen erect view showing multiple central air-fluid levels and dilated small bowel loops suggestive of acute small bowel obstruction.

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CECT abdomen + pelvis: Left side, obturator hernia causing small bowel obstruction [Figure 2a and 2b].

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Figure 2: a) CECT abdomen and pelvis demonstrating herniation of a jejunal loop through the left obturator canal. b) CECT abdomen and pelvis showing dilated small bowel loops with multiple air-fluid levels secondary to left-sided obturator hernia causing intestinal obstruction. (CECT: Contrast enhanced computed tomography)

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Treatment

An exploratory laparotomy via a lower midline abdominal incision was done.

Intra op findings:200 cc bilious peritonitis was present. Incarceration of the distal jejunum loop due to a herniation in the 1 cm defect in the left side of the obturator canal [Figure 3a and 3b]. Jejunal Resection and Anastomosis were done after confirming the vascularity of the resected margins.

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Figure 3: (a) Loop of distal jejunum herniating into left obturator canal, (b) Necrosed margins of loop of jejunum.

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Defect was closed with polydioxanone suture (PDS) 2-0 simple interrupted suture. The pelvic drain was kept. The abdominal wall is closed in layers.

DISCUSSION

An obturator hernia is an uncommon condition with high mortality and morbidity, because of delay in diagnosis and high risk of bowel gangrene. Because females have a wider pelvis and a more triangular obturator canal than males, obturator hernias are more prevalent in females. The majority of patients are identified during an exploratory laparotomy since the preoperative clinical diagnosis of an obturator is challenging.

Obturator neuralgia or a palpable mass between the pectineus and adductor longus muscles in the upper thigh are two possible presentations of an obturator hernia.^5,6 The Howship-Romberg sign, a symptom of strangulated bowel in the obturator canal, may be used to support obturator neuralgia. In this sign, the patient has higher groin pain on the same side when they extend, adduct, and rotate a thigh medially. It results from the cutaneous branch of the obturator nerve being compressed by the hernia’s contents.

A CECT scan may accurately diagnose the source of intestinal obstruction. Additionally, it may detect any perforation and vascular impairment. Due to its smaller hernial orifice, Richter’s type is often more common.

Smaller defects are to be primarily closed utilizing a nonabsorbable interrupted suture. If the defect is more than one centimeter, a mesh must be utilized to repair it. Prosthetic mesh should not be used if there is peritonitis due to perforation of the bowel or strangulation. There is a high chance of the need for bowel resection as there is a delay in the diagnosis, leading to bowel necrosis. In the presence of intestinal obstruction or perforation and poor general condition of the patient, an emergency laparotomy should be done.

CONCLUSION

An obturator hernia is an uncommon condition that could result in high rates of mortality due to difficult diagnosis and a high chance of development of bowel strangulation. This should be included in the differential diagnosis for an emaciated elderly female patient presenting with severe intestinal blockage. The diagnosis is a CECT scan. Early surgery with primary closure of the defect, without mesh use, is regarded as safe because of the potential risk of delayed intestinal necrosis resulting from intestinal strangulation.