JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Obturator Hernia, 'The Little Old Lady Hernia'
Taylor Carter, BA, David H. Ballard, MD, Peeyush Bhargava MD, MBA, Navdeep S. Samra, MD
Obturator hernia is a rare type of abdominal hernia that classically presents in elderly women. We report the case of 78-year-old woman with progressive vomiting, obstipation, and abdominal pain. Contrast-enhanced computed tomography showed a left-sided obturator hernia, which was confirmed and treated at laparotomy. Demographics, symptoms, imaging findings, and management of obturator hernias is reviewed.
INTRODUCTION
was repaired using two figure of eight sutures. The incarcerated bowel initially showed edema and congestion but had no obvious signs of perforation or necrosis. After allowing the incarcerated bowel to rest, the congestion and edema resolved thus no resection was performed. Postoperatively the patient was placed intensive care unit where she had some respiratory issues. Upon investigation, her chronic obstructive pulmonary disease was characterized as terminal Global Initiative for Chronic Obstructive Lung stage 4 with an FEV1 of 26%. She responded and stabilized on bronchodilators and inhalers. The patient’s postoperative recovery course was unremarkable but given her terminal end stage lung disease, she was offered hospice care and was amenable to this course of action.
Obturator hernia is a rare variety of abdominal hernia. A classic presentation is in elderly women with intermittent abdominal colic and pain along the medial aspect of the thigh. Patients with obturator hernia, if not diagnosed and treated promptly, can progress to strangulation and bowel necrosis, leading to significantmorbidityandevenmortality. Computed tomography (CT) is a sensitive imaging modality, and treatment consists of open or laparoscopic repair. 1 The following case outlines the treatment course of an elderly woman who presented with bowel obstruction from an obturator hernia and underwent successful surgical repair.
CASE PRESENTATION
A 78-year-old multiparous woman presented to the emergency department with a five-day history of abdominal pain, nausea, vomiting, anorexia, and obstipation. Emesis was initially described as frequently occurring after meals and progressed to feculent - described as brown in color with a foul odor, without bile or blood. The patient denied fever, chills, worsening of baseline shortness of breath, or chest pain. Pertinent past medical history included ischemic strokewith residual blindness, chronic obstructive pulmonary disease from extensive smoking, and peptic ulcer disease. She denied prior abdominal surgery. Physical exam revealed a distended abdomen with bulge and point tenderness in the right groin area. Digital rectum exam revealed no masses or blood. Pertinent labs revealed leukocytosis, hemoconcentration, elevated blood urea nitrogen, hyponatremia, and hypochloremia. CT showed a massively distended stomach, dilatation of the proximal jejunum with a transition point, and a left-sided herniated small bowel loop between the obturator externus and pectineus muscles (Figure 1A and 1B). After brief resuscitation and nasogastric tube insertion, the patient was taken urgently to the operating room. At laparotomy, intraoperative assessment was significant for dilated stomach, moderate amounts of serous fluid, and a Richter type hernia in the obturator foramen (Figure 2). The hernia was then reduced, and the left obturator canal defect
Figure 1: A. Contrast-enhanced CT axial image at the level of the pubic symphysis showing the herniated small bowel loop (solid arrow) between the obturator externus and the pectineus muscles.
96 J La State Med Soc VOL 169 JULY/AUGUST 2017
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