Urgent Laparotomy is Required
This 83-year-old patient has a strangulated obturator hernia causing small bowel obstruction, and immediate surgical intervention via urgent laparotomy is mandatory. The correct answer is (c) urgent laparotomy.
Clinical Reasoning
Diagnostic Features Point to Obturator Hernia
The clinical presentation is pathognomonic for an obturator hernia:
- Howship-Romberg sign: Pain in the medial aspect of the right thigh occurs when the herniated bowel compresses the obturator nerve 1
- Palpable rectal mass: The hernia sac can be felt on rectal examination as it protrudes through the obturator foramen 1
- Small bowel obstruction symptoms: Vomiting and abdominal distension indicate mechanical obstruction 2
Obturator hernias are notoriously difficult to diagnose and frequently present with recurrent symptoms before the correct diagnosis is made 1. This patient's age (83 years), female sex, and likely malnourished state are classic risk factors 1.
Why Immediate Surgery is Mandatory
In patients with small bowel obstruction from strangulated hernia, immediate surgical treatment is required to prevent bowel necrosis, perforation, and death 3. The mortality rate can reach 25% when ischemia develops 3.
Key indicators demanding urgent surgery in this case:
- Complete obstruction: Vomiting and distension suggest high-grade or complete obstruction requiring surgical intervention 2
- Strangulation risk: Any incarcerated hernia with bowel obstruction carries high risk of strangulation 3
- Obturator hernias have exceptionally high strangulation rates: These hernias have narrow necks and frequently contain only part of the bowel wall (Richter-type hernia), making ischemia likely even without complete obstruction 1
Why Other Options Are Inappropriate
Option (a) - Conservative management: While nasogastric decompression and IV fluids are appropriate initial resuscitation measures, observation alone is dangerous in suspected strangulated hernia 2. Conservative management should never delay surgical intervention when strangulation is suspected 3.
Option (b) - Sigmoidoscopy and drainage: The rectal mass is not an abscess or rectal pathology—it is herniated small bowel palpable through the rectal wall. Sigmoidoscopy would be both non-diagnostic and potentially harmful 1.
Option (d) - Gastrografin study: Contrast studies have no role when strangulated hernia is suspected clinically. Imaging should not delay surgical treatment in hemodynamically stable patients with clear surgical indications 3. The diagnosis is clinical, and delaying surgery for imaging risks bowel necrosis.
Option (e) - Right groin exploration: While the hernia does require repair, groin exploration would miss an obturator hernia, which exits through the obturator foramen in the pelvis, not the inguinal canal. Laparotomy (or laparoscopy) is required to access the obturator canal and assess bowel viability 1.
Surgical Approach
The appropriate surgical approach is laparotomy with:
- Reduction of the incarcerated bowel from the obturator canal 1
- Assessment of bowel viability—resection if necrotic, preservation if viable 3
- Primary repair of the obturator defect using suture technique 1
- In elderly patients with comorbidities, the surgical approach should be open rather than laparoscopic to allow rapid assessment and intervention 3
Critical Pitfalls to Avoid
Do not delay surgery for imaging: CT scan may confirm the diagnosis but should not delay operative intervention when clinical findings are diagnostic 3, 1
Do not attempt conservative management: Unlike some cases of adhesive small bowel obstruction that may resolve with conservative treatment, strangulated hernias require immediate surgery 2. The failure rate of conservative management approaches 100% in incarcerated hernias with obstruction 3.
Do not miss the diagnosis: Obturator hernias are frequently misdiagnosed initially because the hernia is not visible externally and the thigh pain may be attributed to other causes 1. The combination of bowel obstruction + medial thigh pain + palpable rectal mass is diagnostic.