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OBTURATOR HERNIA CASE REPORT: EARLY DIAGNOSIS WITH THE HELP OF COMPUTED TOMOGRAPHY

An obturator hernia accounts for 0.2–0.4% of all small bowel obstructions (SBO).1 It classically occurs in thin elderly women and can cause pain radiating down the medial thigh, exacerbated by adduction/extension of the hip or the medial rotation of the knee (Howship–Romberg sign, positive in 25–50%). The diagnosis is commonly delayed or missed, and hence, it carries a high mortality rate of 25%.2 The hernia occurs down the obturator canal just beneath the superior pubic ramus, where the obturator nerve and vessels pass through the tough fibrous obturator membrane. A thin 83-year-old otherwise well woman presented with 24 h of absolute constipation, nausea and vomiting. She had a similar self-limiting episode 6 months previously. Her only surgical history was a perforated appendix at age 19. On examination, she was distended but had no palpable hernias. Plain films showed a SBO, blood tests revealed a White cell count of 11.3 and a C-reactive protein of 63. She was admitted for conservative treatment. Computed tomography (CT) scan was arranged after 24 h as the cause was not yet clear and she had not settled clinically (Figs 1,2). The radiologist diagnosed an obturator hernia. She proceeded to have a subumbilical midline laparotomy; the neck of the defect was widened bluntly with a finger and an incarcerated Richter’s hernia was reduced. The herniated segment was viable and no resection undertaken. The sac was closed with a prolene pursestring suture and a second layer continuous stitch. The patient recovered well and was discharged home 5 days postoperatively. An obturator hernia, although rare, must be considered particularly in the frail elderly population. CT is a reliable imaging modality and aids in diagnosing 783–100%4 of cases preoperatively. Varied repair techniques have been described: sac ligation alone, direct suture repair, use of autologous tissue or mesh repair.5 Closure of the obturator canal itself is controversial, as the obturator membrane is relatively rigid and difficult to approximate, and recurrence rate is only 0–10% in cases without canal closure.6 REFERENCES