Effective Treatment for Incarcerated Obturator Hernia With Bowel Dilatation by Combined Laparoscopy and Preperitoneal Approach: A Case Report

Obturator hernia is a rare form of abdominal hernia commonly observed in elderly women.^1–3 Clinical diagnosis is difficult because of nonspecific symptoms. Computed tomography (CT) is a valuable tool for preoperatively diagnosing obturator hernia; an early diagnosis reduces morbidity and mortality. Although obturator hernia is primarily treated by surgery, recurrence and infection should be carefully monitored. Obturator treatment by laparoscopic approach has recently reported, but that approach cannot be preferred in cases with ischemia/necrosis or bowel dilatation as ileus.^4,5 In some cases, clinically occult bilateral obturator hernias are detected during surgery.⁶ Here, we report a case where a surgical technique combining laparoscopy and preperitoneal space approach via a small lower abdominal median incision was effective for treating obstructed and bilateral obturator hernias with bowel dilatation, which were unexpectedly detected during surgery.

Case Report

A 90-year-old woman with a history of percutaneous coronary intervention for acute cardiac syndrome, cerebral infraction, and hypertension presented to our hospital with a 2-day history of abdominal pain, nausea, and vomiting. She had given birth to 3 children but had not undergone any abdominal surgeries. Her body weight was 32 kg, her height was 132 cm, and her body mass index was 19.1 kg/m². A physical examination revealed mild abdominal distension. Additionally, she reported lower abdominal pain; however, no abdominal sensitivity or muscular defense was observed. She experienced pain in her right hip, which increased with the extension and abduction of the thigh. This finding was suspected to be the Howship–Romberg sign. Blood tests revealed high levels of C-reactive protein (3.1 mg/dL), blood urea nitrogen (49 mg/dL), and creatinine (0.96 mg/dL). Other blood test results were normal.

Abdominal X-ray revealed dilated small bowel loops. CT imaging suggested a right obturator hernia comprising an obstructed small intestinal loop (Fig. 1). She underwent an emergency operation with a diagnosis of incarcerated obturator hernia.

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Under general anesthesia, hernioplasty was laparoscopically initiated using 3 trocars: a 12-mm umbilical trocar for the camera that was placed using the Hasson technique and two 5-mm trocars that were placed on each side of the umbilical region as working ports (Fig. 2). Abdominal air pressure was set at 10 mmHg, and the entire small intestine was dilated. A flexible camera was introduced into the peritoneal cavity. The small intestinal loop was incarcerated in the right obturator canal (Fig. 3A). Next, the peritoneum was incarcerated into the left obturator canal (Fig. 3B). Thus, the small intestine was laparoscopically reduced, and no signs of small intestinal ischemia or perforation were observed. Subsequently, using a small lower abdominal median incision (approximately 4 cm), the right preperitoneal space was accessed, and a Modified Kugel Hernia patch (C.R. Bard/Davol, Warwick, Rhode Island) was applied. On the left side, the same procedure was performed using the same lower abdominal incision. Finally, the bilateral mesh was laparoscopically confirmed for its position in the appropriate space (Fig. 3C). The total operating time was 68 minutes, and the volume of blood lost was 10 mL. On postoperative day 3, a liquid diet was initiated for the patient, and she was subsequently discharged on postoperative day 10 without any postoperative complications. At 18-month follow-up, the patient exhibited no signs of recurrence.

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Discussion

Obturator hernias account for only 0.07% to 1% of all hernias and are rare among abdominal wall hernias. Obturator hernias primarily occur in elderly multiparous women.^1–3 Compression of the obturator nerve by the hernia can cause pain or cramps from the groin to the knee. Classical symptoms of such hernias include adduction and internal rotation of the thigh, the Howship–Romberg sign, but this symptom is not observed in all cases.² CT is useful for preoperatively diagnosing obturator hernia, as reported by Meziane et al⁷ and confirmed by subsequent studies.^2,8–10 Indeed, CT was also useful for diagnosis in this case. However, occult inguinal hernia could not be diagnosed.

Currently, there is no established technique for treating obturator hernia. Laparoscopic surgery has been reported in several cases and is suitable for most patients except for those with peritonitis and bowel ischemia.^4,5 Here, we repaired the hernia using a surgical technique combining laparoscopy and preperitoneal space approach via a small lower abdominal median incision. The characteristic feature of this surgical technique is that the wound area of laparoscopy and that of mesh insertion are separate. Additionally, laparoscopy offers the advantage of definitive diagnosis and treatment, monitoring intestinal strangulation and condition, assessing bilateral obturator hernia, and verifying the position of the inserted mesh. The advantages of the preperitoneal space approach via a small lower abdominal median incision are that the surgeon can approach the bilateral obturator foramen from the wound site; the viewing field is not blocked by bowel dilatation. In addition, it can be performed without contaminating the mesh insertion even though it was used over the wound area of laparoscopy during intestine resection, performed as necessary. The recurrence rate of hernia is low, and closure of the hernia orifice is usually performed by direct suture and plugging and patching.¹¹ Mesh is effective in preventing recurrence, although there are concerns regarding a possible infection.¹² Thus, combining the 2 techniques provides all of the aforementioned advantages while decreasing the risk of recurrence and infection. There are several reports of bilateral obturator hernia not being diagnosed by preoperative examination^6,13,14; thus, this procedure is useful for detecting and treating obturator hernia on the opposite side. In addition, the laparoscopic procedure associated with mesh was unnecessary, and the viewing field was not hindered by bowel dilatation in the preperitoneal space approach. Therefore, operative procedure is comparatively simple.

Although obturator hernia must be surgically treated, there is no established technique for this. Thus, the surgical technique should be chosen on a case-by-case basis. The combined technique described here has many advantages and can be a potential treatment option for obturator hernia.