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Diagnosis of an obturator hernia by CT
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  1. Scarlet Nazarian1,
  2. Aravindan Narayanan2,
  3. Sebastian Chang3
  1. 1Department of Surgery, East & North Herts NHS Trust, London, UK
  2. 2Department of Surgery, East & North Herts NHS Trust, Stevenage, UK
  3. 3Department of Radiology, Lister Hospital, Hertfordshire, UK
  1. Correspondence to Dr Scarlet Nazarian, scarlet.nazarian{at}nhs.net

https://doi.org/10.1136/bcr-2015-212239

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    Description

    Obturator herniae are a rare type of abdominal wall herniae, with an incidence of 0.7–1%.1 They have a high mortality rate of up to 40% due to strangulation,2 and patients often present with non-specific symptoms. The clinical presentation varies, depending on the contents of the hernial sac and the degree of herniation.3 High index of suspicion with rapid preoperative diagnosis is vital.

    A frail 81-year-old woman was admitted with a 72 h history of acute abdominal pain, absolute constipation and vomiting. She also reported pain and paraesthesia along the inner aspect of her right thigh (Howship-Romberg sign). She had never undergone abdominal or groin surgery. On examination, she had a distended abdomen with generalised tenderness and no groin hernias. Rectal examination and bloods were unremarkable. Plain X-rays revealed complete small bowel obstruction with no perforation. A high index of suspicion for an obturator hernia was raised.

    An urgent CT scan revealed an incarcerated right obturator hernia containing small bowel loop, confirming our clinical suspicion (figure 1).

    Figure 1
    Figure 1

    Significant small bowel obstruction noted. Right obturator hernia with dilated proximal loop of bowel seen at the hernia neck and mid/distal ileum strangulated within the hernia. Trace of fluid in hernia sac.

    At laparotomy, a strangulated segment of small bowel was resected from the right obturator hernia defect and the defect was closed with PDS sutures. The patient made a good recovery. A high index of suspicion, radiological adjuncts and prompt intervention (operated within 6 h from presentation) were integral for better outcome.

    This case reiterates the importance of prompt recognition of obturator herniae. In the presence of bowel obstruction coupled with a positive Howship-Romberg sign, an obturator hernia must be considered.

    Learning points

    • Although rare, an obturator hernia must be considered in the setting of intestinal obstruction coupled with a positive Howship-Romberg sign.

    • Urgent CT scanning should be sought for early preoperative diagnosis of an obturator hernia.

    • Surgical treatment should be undertaken in cases of strangulated obturator herniae.

    References

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      1. Uludag M,
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      . A rare cause of intestinal obstruction: incarcerated femoral hernia, strangulated obturator hernia. Hernia 2006;10:288–91. doi:10.1007/s10029-006-0074-6
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      1. Kassir R,
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      . Management of spigelian hernia caused by necrobiotic fibroma of the uterus in a pregnant woman. Int J Surg Case Rep 2013;4:1176–8. doi:10.1016/j.ijscr.2013.10.010
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    Footnotes

    • Contributors AN was the surgical registrar on-call who admitted the patient. The patient remained under the care of AN and SN. SN wrote the case report, which was revised by AN. SC provided images for the case report.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.