Discussion -
The protrusion of abdominal viscera through the obturator canal is known as an obturator hernia. The obturator nerve and vessels are located inside this 2-3 cm long and 1 cm broad structure, which is bordered inferiorly and laterally by the obturator membrane and superiorly and laterally by the pubic bone.1Corpus adiposum serves as a cushion for the obturator nerve.1 It is particularly prevalent in older women aged 70-90 due to loss of the protective fat (Corpus adiposum) in the obturator canal, which predisposes hernia development, hence the title ”little old woman’s hernia.”5Women have this condition 6–9 times more frequently due to their wider pelvis and greater obturator canal than males.3Pregnancy, kyphoscoliosis, chronic lung illness, constipation, chronic urinary obstruction can all increase intra-abdominal pressure, which increases the risk of herniation.7 In this case, the patient had multiple pregnancies, chronic obstructive pulmonary disease, and constipation, all of which increase the risk of herniation. Because the sigmoid colon tends to prevent herniation on the left, it occurs more frequently on the right side.3However, in this instance the herniation was on the left side.
Because the signs and symptoms are frequently non specific, it is estimated that only 20-30% of obturator hernia patients receive a correct preoperative diagnosis.8A palpable protrusion in the obturator region (medial thigh) is typically absent due to its deep location.9 Pelvic CT scans, on the other hand, have been useful in the diagnosis of obturator hernia.10According to the literature, up to 80% of patients with obturator hernias have symptoms of bowel obstruction, which is often partial due to a high proportion of patients having Richter’s herniation of the bowel into the obturator canal.10The Howship Romberg (HR) sign manifests as pain along the medial aspect of the thigh or knee caused by hernia sac compression of the obturator nerve within the canal; while considered pathognomonic, its sensitivity is low and specificity varies widely.11Typically, this pain is exacerbated by extension and abduction or inward rotation of thigh.
Obturator hernia has three stages. The first step includes the entry of preperitoneal tissue into the pelvic opening of the obturator canal, whereas the second stage involves the formation of a dimple in the peritoneum and leads to the formation of a peritoneal sac overlaying the canal. During the third stage symptoms are caused by the herniation of the viscera into this sac.1,3,12
Actually, emergency multidetector CT scanning could result in more rapid diagnosis and earlier surgical intervention, improving the outcome. Meziane et al. reported the first use of a CT scan to detect obturator hernia in 1983.13A herniated loop of distal small bowel extending through the obturator foramen between the pectineus and obturator externus muscles is a common CT scan finding. CT scan of an incarcerated hernia reveals associated bowel loop dilatation in the abdomen and in severe cases, the bowel becomes edematous and ischemic, leading to gangrene and perforation.13According to some reports, the use of CT scan has increased the rate of preoperative diagnosis from 43% to 90%.5Other diagnostic methods, such as abdominal x-ray, herniography, ultrasonography, and gastrointestinal imaging with contrast medium, have been reported to be useful. Plain abdominal x-ray films can show gas in the obturator region, indicating a hernia.4
Obturator hernia can only be treated surgically . In an emergency, an abdominal approach through a low midline incision is preferred. Because of gangrene or perforation, resection of the involved portion of bowel is sometimes required.13