Obturator Hernia: Characteristics and Diagnosis
Obturator hernia is most common in older women with cachexia (option A is correct), as it typically affects elderly, emaciated, multiparous women due to loss of supporting connective tissue and the wider female pelvis 1, 2.
Epidemiology and Risk Factors
- Rare condition representing less than 1% of abdominal hernias
- Responsible for 0.05-1.4% of cases of mechanical small bowel obstruction 1
- Predominantly affects:
- Elderly women (70-90 years old)
- Malnourished/cachectic individuals
- Multiparous women
- Patients with conditions causing weight loss
Clinical Presentation
- Intestinal obstruction is the most common presentation
- Howship-Romberg sign: pain along the medial aspect of the thigh referred to the knee due to compression of the obturator nerve 3
- This is NOT in the sciatic nerve distribution (option B is incorrect)
- Intermittent colicky abdominal pain and vomiting 4
- Rarely presents as a palpable mass on the medial aspect of thigh
Diagnostic Approach
- CT scan is the gold standard for diagnosis 2, 3
- Shows bowel distension with an ileal loop incarcerated in the obturator foramen 1
- Ultrasonography may show small bowel obstruction but is less specific 2
- Plain radiographs may show signs of intestinal obstruction but are not diagnostic
Surgical Management
- Surgery is the only treatment option 2
- Approaches include:
- Transabdominal approach (laparotomy) - indicated for complete bowel obstruction or suspected peritonitis
- Extra-abdominal approach - for preoperatively diagnosed cases without strangulation
- Laparoscopic approach - minimally invasive with reduced morbidity
- The repair is NOT performed through a transverse incision in the upper medial thigh (option C is incorrect)
Complications
- Strangulation is a frequent complication 1
- Obturator hernias are commonly strangulated at presentation (option D is incorrect)
- High morbidity and mortality rates due to delayed diagnosis
- Bowel resection is often necessary due to strangulation
Key Points for Clinical Practice
- Maintain high clinical suspicion in elderly, thin women presenting with intestinal obstruction
- Early diagnosis through CT imaging is crucial to reduce morbidity and mortality
- Prompt surgical intervention is essential as strangulation is common
- The hernia sac typically contains small bowel, especially ileum 2
Obturator hernia remains a diagnostic challenge due to its rarity and non-specific presentation. The mortality rate can be significantly reduced with early diagnosis and prompt surgical intervention.