A rare case report of an obturator hernia in a 110-year-old woman

Authors

Abstract

Obturator hernias are extremely rare. Since obturator hernia does not have specific signs and symptoms, it is difficult to diagnose it in the emergency department. It is usually seen in women who are elderly, weak, and have chronic diseases. It should be considered in the differential diagnosis when ileus occurs along with abdominal pain, nausea, and vomiting. The treatment is surgery, and delay in diagnosis leads to a high mortality rate. We present the case of a 110-year-old woman with an obturator hernia that caused intestinal obstruction. The hernia was detected early by abdominal computed tomography (CT), and she was taken to emergency surgery. The hernia defect was repaired with polypropylene mesh. The patient was discharged with full recovery, and no recurrence was observed during follow-up.

Keywords

Introduction

Obturator hernias are extremely rare, occurring in less than 1% of all abdominal hernias ¹. These have the highest mortality among all abdominal wall hernias due to the delay in diagnosis and the complications that develop as a result ². Obturator hernias, unlike other hernias, rarely appear with a palpable swelling on physical examination, so they are usually not diagnosed or come to mind. These hernias often occur in weak, elderly, multiparous women and people with increased intra-abdominal pressure ³. Obturator hernias are mostly of the Richter type and are difficult to diagnose because focal strangulation of the intestine can proceed to necrosis without symptoms. Although different imaging methods are used in diagnosis, computed tomography (CT) has superior sensitivity and accuracy than other methods ⁴. Here, we present a case of obturator hernia who presented to the emergency department with abdominal pain, was detected by abdominal CT, and underwent emergency surgery.

Case Presentation

A 110-year-old woman was admitted to the emergency department with abdominal pain that had been going on for 10 days and was accompanied by nausea and vomiting for the last 3 days. The patient had no chronic illness, no medication used regularly, and no previous abdominal surgery. Her body weight was 39 kg. On physical examination, bowel sounds were not heard, there was distension in the abdomen, and there was no defense or rebound. No mass was palpated in the bilateral inguinal region. Rectal examination was normal. Other system examinations were normal. Laboratory results showed c-reactive protein (CRP) 11,1 mg/L, albumin 28,80 g/L, white blood cell count (WBC) 14,7 10^9/L, and other parameters were normal. An abdominal CT scan revealed a severe intestinal obstruction in the left obturator canal (Figure 1(A)). The proximal part of this area appeared dilated, and the distal part collapsed. She underwent emergency surgery. The hernia sac was reached through the left inguinal approach. A Richter-type small bowel loop herniated into the left obturator canal was observed (Figure 1 (B, C)). The wall of the strangulated intestinal segment was intact, its blood supply and movement were observed naturally. No necrosis was observed, and no resection was performed. The obturator hernia was repaired with polypropylene mesh. After the operation, the patient was monitored in the intensive care unit for 2 days due to her advanced age and was discharged 10 days later. No recurrence was observed at the one-year follow-up.
This study was approved by the Ethics Committee of Siirt University (Date: 2024-10-31, No: 7796).

Discussion

Obturator hernias occur most often in older, weak women ⁵. The hernial sac usually includes the small intestine but may also include the appendix, Meckel’s diverticulum, omentum, ovary, fallopian tube, and uterus. This hernia is approximately 6 to 9 times more common in women than in men and usually affects women between the ages of 70 and 90. An obturator hernia is most commonly seen clinically with nausea, vomiting, abdominal pain, bloating, and intestinal obstruction, but these are not specific to this hernia ⁶. Because the symptoms are not specific to obturator hernia and physical examination findings are often absent, the diagnosis of obturator hernia cannot usually be made until laparotomy is performed due to intestinal obstruction or peritonitis. These hernias cause a high mortality rate of 25-47,6%. Since obturator hernia symptoms are often attributed to more benign causes, such as constipation, a delay in diagnosis is a common feature. CT is the imaging method with the highest sensitivity and specificity ⁷. Rapid diagnosis and early surgical intervention are performed with an urgent abdominal CT scan. The CT finding is herniation of the intra-abdominal tissue extending through the obturator foramen. With the introduction of CT scanning, the preoperative diagnosis rate increased from 43% to 90% (5). In our case, the diagnosis was made by abdominal CT (Figure 1, (A)).
Treatment of obturator hernia is surgery ⁸. In this case, surgery was performed through the inguinal approach; other surgical approaches are retropubic, transperitoneal, and laparoscopic. Although the use of mesh in obturator hernias is controversial, in this case, the hernia was repaired using polypropylene mesh, but this is not fully described in the literature. Although it is debated whether the use of mesh contributes to the strength of hernia repair, a study found that the 3-year recurrence rate was 0% with the mesh and 22% without the mesh. No hernia recurrence was observed in our patient’s 1-year follow-up.
This case aims to remind us of the importance of considering obturator hernia in the differential diagnosis of a patient with intestinal obstruction.

Conclusion

Obturator hernia must be considered in the differential diagnosis in elderly patients with symptoms of intestinal obstruction. An abdominal CT scan should be performed to avoid delay in diagnosis.

Declarations

References

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About This Article

Received:

December 3, 2024

Accepted:

January 13, 2025

Published Online:

January 26, 2025