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LETTER TO EDITOR
Year : 2013  |  Volume : 1  |  Issue : 2  |  Page : 58-59

Obturator hernia: Rare cause of small gut obstruction


Department of Radiodiagnosis and Imaging, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Web Publication15-Jan-2014

Correspondence Address:
Naseer Ahmad Choh
Department of Radiodiagnosis and Imaging, Sher I Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.125041

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How to cite this article:
Choh NA, Shaheen F, Robbani I. Obturator hernia: Rare cause of small gut obstruction. Saudi Surg J 2013;1:58-9

How to cite this URL:
Choh NA, Shaheen F, Robbani I. Obturator hernia: Rare cause of small gut obstruction. Saudi Surg J [serial online] 2013 [cited 2020 Jul 12];1:58-9. Available from: http://www.saudisurgj.org/text.asp?2013/1/2/58/125041

Sir,

An elderly female presented with a subacute history of colicky abdominal pain with few episodes of vomiting that had lasted for 2 months. Physical examination revealed mild abdominal distension with pallor in a thin, lean patient.

Routine investigations were unremarkable. Ultrasonography abdomen showed distension of small gut loops.

Contrast enhanced spiral computed tomography (CT) was performed. Marked small gut distension was observed with a distal ileal loop herniating into the left obturator canal between the pectineus and obturator externus muscle [Figure 1] and [Figure 2]. The efferent ileal loop exiting from the obturator canal was collapsed. Large gut was normally collapsed.
Figure 1: Axial scans at umbilical level shows distended small bowel loops and the collapsed colon

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Figure 2: Axial computed tomography at the level of symphysis pubis shows an ileal loop herniating into the left obturator canal between the pectineus and obturator externus muscle

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Liver, spleen, pancreas and kidneys were unremarkable. No free intraperitoneal fluid was seen at the time of CT examination. Laparotomy was done a few days after the CT and the findings were confirmed. The defect was repaired by interrupted sutures. The postoperative period was unremarkable.

Due to its uncommon incidence, deep location and infrequent specific signs or symptoms, the clinical diagnosis of obturator hernia is difficult.Yet early diagnosis cannot be overemphasized because the delay in its recognition may contribute to the poor prognosis of these patients. The site of this uncommon herniation is the obturator canal in the superolateral aspect of the obturator foramen. It is an obliquely oriented fibro-osseous tunnel measuring about 2-3 cm long and 1 cm in diameter through which the obturator nerve and vessels course. [1],[2],[3] Elderly women are most commonly affected and this is thought to be due to the obliquity of the obturator canal within the wider and more relaxed perineum of women who have had multiple pregnancies. Other factors that increase intraabdominal pressure have also been recognized as predisposing conditions. [2],[4] The contents of an obturator hernia can lie between the pectineus and obturator externus (as in this case), between the superior and middle fascicules of the obturator externus muscles, or between obturator internus and obturator externus muscle.

Approximately 80-90% of obturator hernias occur elderly, emaciated women, they are more common on the right and usually contain ileal loop, but other viscera as pelvic adnexa may also be involved. [3] The anatomic osteomuscular planes of the lower pelvis in the area of the obturator canal are well-displayed by high resolution CT scans. The obturator foramen is formed by the continuity of the pubic and ischial bones. It is covered by the obturator membrane, except in the anterosuperior aspect where it is perforated by the obturator artery, vein and nerve which travel along the 2-3 cm oblique tunnel formed by the internal and external obturator muscle (obturator canal). [2],[4],[5] Most patients present with acute or recurrent bowel obstruction and a tender mass in the obturator region on rectal or vaginal examination. About half the patients experience pain radiating along the medial aspect of thigh when the leg is extended or abducted (Howship-romberg sign) due to the obturator nerve compression by hernia. [1],[2],[3] Rarely, subcutaneous emphysema with or without associated infection in the thigh secondary to herniated bowel perforation can also be seen. [1] The radiologic diagnosis of obturator hernia should be considered whenever abdominal radiographs a barium studies show bowel obstruction together with a fixed loop containing some gas or contrast medium in the obturator region. [1],[6] CT of the pelvis is most valuable in revealing the hernia as a soft-tissue mass or opacified loop the protrudes through the obturator foramen and extends between the pectineus and the obturator muscles. [2],[4],[5],[7] The management of obturator hernia consists of emergency laparotomy following a clinical suspicion if peritoneal signs are present; if peritoneal signs are absent, a CECT of abdomen and pelvis can be performed for confirmation of the diagnosis before further operative management. The hernial defect may be repaired through a transabdominal approach or laparoscopically, using a mesh or interrupted sutures. [8],[9] We conclude that the obturator foramina should be specifically examined in cases of intestinal obstruction of obscure etiology, especially in elderly females, and this case is intended to make radiologists and surgeons more familiar with this entity.

 
  References Top

1.Wantz GE. Abdominal wall hernias. In: Schwartz SI, editor. Principles of Surgery. 6 th ed. New York: McGraw-Hill; 1994. p. 1517-43.  Back to cited text no. 1
    
2.Cubillo E. Obturator hernia diagnosed by computed tomography. AJR Am J Roentgenol 1983;140:735-6.  Back to cited text no. 2
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3.Harrison LA, Keesling CA, Martin NL, Lee KR, Wetzel LH. Abdominal wall hernias: Review of herniography and correlation with cross-sectional imaging. Radiographics 1995;15:315-32.  Back to cited text no. 3
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4.Mercader VP, Fein DA, Gembala-Parsons RB, Caroline DF. CT of an obturator hernia. J Comput Assist Tomogr 1995;19:330-2.  Back to cited text no. 4
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5.Meziane MA, Fishman EK, Siegelman SS. Computed tomographic diagnosis of obturator foramen hernia. Gastrointest Radiol 1983;8:375-7.  Back to cited text no. 5
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6.Glicklich M, Eliasoph J. Incarcerated obturator hernia: Case diagnosed at barium enema fluoroscopy. Radiology 1989;172:51-2.  Back to cited text no. 6
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7.Nishina M, Fujii C, Ogino R, Kobayashi R, Kumada K, Yamane K, et al. Preoperative diagnosis of obturator hernia by computed tomography. Semin Ultrasound CT MR 2002;23:193-6.  Back to cited text no. 7
    
8.Chang SS, Shan YS, Lin YJ, Tai YS, Lin PW. A review of obturator hernia and a proposed algorithm for its diagnosis and treatment. World J Surg 2005;29:450-4.  Back to cited text no. 8
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9.Mantoo SK, Mak K, Tan TJ. Obturator hernia: Diagnosis and treatment in the modern era. Singapore Med J 2009;50:866-70.  Back to cited text no. 9
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