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