DISCUSSION
Obturator hernias are typically known for their classical presentation in “little old ladies” and their difficult clinical diagnosis. Risk factors for obturator hernia are increased intra- abdominal pressure which can be caused by conditions such as chronic obstructive pulmonary disease, and multiparity, which were present in the case at hand; additional risk factors include constipation and ascites. 2 Rapid weight loss associated with increased space in the obturator canal is another common risk factor observed in association. 2,3 The increased space appears to ease the entrance of bowel leading to an increased risk of entrapment. The incidence seems to be much higher in females according to one article that states that 85% of patients are female due to their broader pelvis and wider obturator canal. 2 Although predominantly females are affected it can sometimes present in little men in whom malnutrition or chronic illness contributed to weakened tissues around the obturator foramen with ensuing hernia formation. 4 Clinical diagnosis can be quite a challenge due to the vague symptoms at presentation. 5 In most cases, patients present with non-specific aching or dull abdominal pain with nausea and vomiting. In rare instances, pain in the distribution of the obturator nerve can be described and are clinically described as the Howship-Romberg sign. 5 Prompt diagnosis is important because obturator hernias have the highest mortality amongst other abdominal wall hernias with rates as high as 40%. 6,7 The mortality is due to strangulation of the bowel, which can cause necrosis, rupture, and eventually, lead to bacterial peritonitis with associated significant morbidity and mortality even when treated. The increased mortality is also associated with the multiple comorbidities and the older age of the “characteristic” obturator hernia patients. 8 In one retrospective study of 20 consecutive patients with obturator hernia, the mortality rate was noted to be 47.6%. 9 Diagnosis is established by CT imaging, which allows one to view the obturator canal and the contents protruding through it. It confirms bowel obstruction, identifies the transition point at the level of the obturator canal, and can also identify necrotic bowel. Typically, the CT is performed with oral and IV contrast, but sometimes patients with bowel obstruction do not tolerate oral contrast. In such a situation CT is performed only with IV contrast. Although CT is a valuable tool, according to one specific case an obturator hernia was not noticed because it only contained a small part of the bowel wall, which is called a Richter type hernia. 5 Richter type hernias are an abdominal hernia in which only part of the circumference of the bowel is entrapped and strangulated in the hernial orifice. 10 Many times the diagnosis can be presumed, but confirmation usually occurs intra-operatively. After diagnosis, immediate surgical repair is indicated to prevent further ischemia, necrosis, and risk of perforation, which could lead to peritonitis, septic shock and death. 11 Although open repair is a commonly used and effective method of reducing abdominal hernias including obturator hernias, laparoscopic repairs have been described and may become the preferred
Figure 1: B. CT Scan Coronal Reconstruction– Dilated stomach (asterisks) and small bowel (dashed arrow) loops are consistent with small bowel obstruction. Left obtura- tor hernia (solid arrow) is also seen.
Figure 2 : Intraoperative view of Richter Type obturator hernia.
J La State Med Soc VOL 169 MARCH/APRIL 2017 97
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