Obturator Hernia: A Diagnostically Challenging Source of Abdominopelvic Pain 1Donald
Herman
1 Dhillon ,
John Hines,
and Barbara Zucker School of Medicine at Hofstra/Northwell,
Introduction An obturator hernia is a rare type of abdominal hernia in which contents from the abdomen can protrude through the obturator canal, a passageway at the superior aspect of the obturator foramen through which the obturator neurovascular bundle (nerve, artery, and vein) passes. The canal is bordered inferiorly by the obturator membrane, a thin aponeurosis at which the obturator internus and externus muscles attach, and superiorly by the superior pubic ramus. Weakening of the obturator membrane leads to widening of the obturator canal, resulting in herniation of contents either anteromedially to the neurovascular bundle or splaying the neurovascular bundle apart.[1]
2 MD
2Northwell
Radiographic Imaging A
A: Axial non-contrast enhanced CT image through the abdomen demonstrates dilated bowel loops
B
Case Report A 70-year-old woman presented with lower abdominal pain, distention and vomiting. Physical exam revealed tenderness to palpation in the right groin. No mass or hernia sac was palpated. Results of complete blood count and serum metabolic panel were normal.
B: Axial non-contrast enhanced CT image demonstrating dilated bowel loops (arrow)
C
Discussion There are three types of obturator hernias (type I, II, and III) that are classified based on the severity of the hernia. Obturator hernias are difficult to diagnose as they are rare and often have non-specific signs and symptoms making it, historically, the abdominal wall hernia with the highest mortality rate.
Health Huntington Hospital Physical exam is difficult to utilize in the diagnosis of obturator hernias due to the pectineus muscle overlying the region of the hernia. The use of CT scan is the standard for diagnosing obturator hernias preoperatively as CT provides high sensitivity and specificity. Ultrasonography of the inguinal and inner thigh region can also provide important diagnostic information about obturator hernias including the degree of bowel dilation, the level of obstruction, the potential involvement of the large bowel, and the presence of bowel [2] peristalsis.
Prognosis, Treatment, and Therapeutic Options Patients that are diagnosed with an obstructing obturator hernia must have the hernia repaired either surgically or laparoscopically. Repair of the hernia involves reducing the incarcerated bowel and repairing the hernia via either suture or mesh repair. Bowel resection is required in cases where the herniated portion of bowel is infarcted. Perioperative morbidity and mortality rates are as high as 26.7% and 11.65% respectively.[3]
References Figure 7: Independent CRISPR knockout of CDK4 or CDK6 does not cause dropout in most breast cancer cell lines studied.
C: Axial non-contrast enhanced CT image through pelvis demonstrates a small mass (arrow), consistent with a loop of bowel, lying between the obturator externus muscle and pectineus muscle.
[1] Droukas, Daniel D. et al. Radiographic and surgical findings of type I obturator hernias in patients with refractory groin pain, Clinical Imaging, Volume 55, 35-40, https://doi.org/10.1016/j.clinimag.2019.01.016 [2] Ming-Tse Tsai, Jiann-Ming Wu, Wan-Ching Lien. Obturator Hernia: The “Little Old Lady's Hernia”, Journal of Medical Ultrasound, Volume 22, Issue 2, 2014, Pages 96-98, ISSN 0929-6441, https://doi.org/10.1016/j.jmu.2014.04.004. [3] Schizas, D., Apostolou, K., Hasemaki, N. et al. Obturator hernias: a systematic review of the literature. Hernia 25, 193–204 (2021). https://doiorg.medproxy.hofstra.edu/10.1007/s10029-020-02282-8