Obturator hernia

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Obturator hernia
12893 2021 1125 Fig1 HTML.webp
Abdominal CT scan showing obturator hernia [1]
Specialty General surgery Hernia
Symptoms bowel obstruction
Usual onsetrapid
Risk factors multiparous, underweight, old age, female
Diagnostic method Howship-Romberg sign, abdominal CT scan, Hannington-Kiff sign
Differential diagnosis colon cancer, small bowel obstruction, small bowel hernia
Treatmentsurgery, laparoscopic hernia repair
FrequencyRare (0.07-1% of all hernias)

An obturator hernia is a rare type of hernia, encompassing 0.07-1% of all hernias, [2] of the pelvic floor in which pelvic or abdominal contents protrudes through the obturator foramen. The obturator foramen is formed by a branch of the ischial (lower and back hip bone) as well as the pubic bone. The canal is typically 2-3 centimeters long and 1 centimeters wide, creating a space for pouches of pre-peritoneal fat.

Contents

Etiology

Due to differences in width and inclination of the female pelvis and the larger diameter of the female obturator foramen compared to male anatomy, [3] this hernia is more common in persons assigned female at birth, especially multiparous and older females who are severely underweight for their age and height. [2] [4] The female obturator foramen has been shown to have a triangular opening, while for males it is more oval-like. Childbirth has also been shown to cause multiple structural changes to the muscle, thereby increasing the risk of hernias forming with multiple childbirth. [4] People with lean body builds are also more likely to develop an obturator hernia due to having less adipose and lymphatic tissue surrounding the obturator canal. [2] Nerves and blood vessels that pass through the obturator canal are covered and protected by adipose tissue. When a person experiences significant weight loss due to malnutrition or chronic illness, this protective fatty tissue is lost allowing pelvic and abdominal contents to shift around and increasing the risk of an obturator hernia. Other factors that may increase a person's risk of developing obturator hernia include conditions that increase pressure within the abdomen. Examples of such conditions are: constipation, multiparity, ascities and chronic pulmonary disease (COPD). [1]

Diagnosis

The diagnosis is often made during laparoscopic pelvic exploration after the person arrives at the hospital with signs and symptoms consistent with bowel obstruction. Laparoscopic pelvic exploration is a minimally invasive procedure that allows the surgeon to visually examine the contents of the abdomen without making a large cut. [5] The Howship–Romberg sign is suggestive of an obturator hernia, with about 56.2% (out of 146 patients in a systematic review) of people showing these signs. [2] These signs are worsened by thigh extension, medial rotation and abduction. [6] It is described as a sharp, stabbing pain in the medial thigh/obturator distribution, extending to the knee and is caused by the hernia pushing on the obturator nerve. The Hannington-Kiff sign can also be suggestive of an obturator hernia, which tests the adductor muscle reflex with a hammer whilst applying pressure on the obturator nerve. [7] However, due to its rare form, obturator hernias are difficult to diagnose due to many other possibilities, non-specific symptoms of pain, as well as minimal external signs/symptoms that can be seen without imaging. The current gold-standard for diagnosis of an obturator hernia is through abdominal computed tomography scans (CT scans), which has been used for diagnosis of 84.2% of patients in a recent systematic review for obturator hernias. [2]

Due to the rarity of an obturator hernia, multiple other illnesses may be considered and ruled out before arriving at the diagnosis of an obturator hernia. Intestinal obstruction is the most common other illness that medical teams may suspect a person has, alongside small bowel obstruction, colon cancer, and small bowel hernia. [8]

Prognosis

Due to the rare nature of the obturator hernia, the causes of the hernia is not widely studied, and therefore it is not preventable.

The difficulty of recognizing and diagnosing obturator hernias often leads to delays in treatment. Since surgical treatment of most cases is delayed, the obturator hernia potentially has the highest mortality rate of the abdominal wall hernias. [9] Studies have shown that if untreated, the mortality rate may range from 50-70%. [10]

When a person with increased risk of obturator hernia presents with bowel obstruction, the obturator hernia must be considered. Aging and malnutrition are common factors that can contribute to obturator hernias. [11] Peritoneal fat and lymphatic tissue that acts as a protective layer over the obturator canal will thin out over time, which results in a larger space between the nerves and vessels, creating the space for the hernia to occur. Additionally, conditions that increase intraabdominal pressure can result in relaxation of the peritoneum. [12] Obturator hernias occur more frequently on the right side compared to the left side because the sigmoid colon physically blocks the left obturator foramen, preventing the formation of the hernia.

The formation of an obturator hernia occurs in three stages: the prehernial stage, the developmental stage, and the third stage. [13] During the prehernial stage, preperitoneal fatty tissue enters the opening of the obturator canal. During the developmental stage, the changes from the prehernial stage progress to a hernial sac. This hernial sac may contain the appendix, fallopian tube, omentum, small intestine, or large intestine. The third stage of obturator hernia formation is often characterized with clinical symptoms as a result of an organ entering the obturator canal. [14] Further development of the hernial sac can potentially put pressure on and potentially damage the obturator nerve. A common complication due to delay in treatment is strangulation. [15]

Diagnosis of the obturator hernia often happens during the third stage or strangulation, at which point emergency surgery is the primary treatment to prevent mortality. [15]

Treatment

Given the high likelihood of bowel strangulation associated with obturator hernia, the treatment would be a surgical intervention. Due to the specific anatomical location of the obturator hernia, the surgery would be classified as an emergency procedure. [15]

Laparoscopic approach

Laparoscopic hernia repair is a minimally invasive technique which allows for good visualization of the hernia and potential simultaneous treatment of other abnormalities within the abdomen. [16] Most published case reports have adopted a transabdominal preperitoneal (TAPP) approach. This technique allows the surgeon to check inside the hernia to see if any section of the bowel is trapped or pinched. Based on the surgeon's clinical judgement, a bowel resection may be performed laparoscopically or through conversion to an open operation. [15]

The laparoscopic method, particularly the TAPP repair, first involves creating a pneumoperitoneum. This is typically done using the open Hassen technique. The ports are then strategically positioned about 5cm from the central line just below the umbilicus. The positioning is crucial, especially when assessing the opposite side during a unilateral obturator hernia diagnosis. This is because there is a possibility simultaneous hernias may be overlooked in such cases. [8]

Once the hernial sac becomes visible, it's carefully placed back, with meticulous dissection if needed. The contents within the hernia, especially any bowel portion would be examined. In cases where a section of the bowel is present, a surgical removal might be warranted, following standard surgical procedures. Sometimes, the extra hernial sac is left as is to avoid over-dissecting. [15]

Open approach

The open surgical procedure for a strangulated hernia would involve a lower midline laparotomy. Through this incision, the hernia is located and its internal contents would be examined by the surgeon. The decisions about potential removal and anastomosis are made. Following this, the hernial opening gets fixed either using direct stitching or by inserting a mesh. [17] While alternative techniques such as the retropubic and inguinal methods exist, they're best done by surgeons well-versed in these particular procedures. The lower central abdominal incision remains a prevalent choice due to its widespread familiarity and reduced risked of complications. [18]

Mesh repair

Towards the end of the process, a mesh may be placed to reinforce the repaired area. Using a synthetic mesh to reinforce the repair has become more common, especially in recurrent or larger defects. This involves making a cut on the front side of the stomach using an electrical surgical instrument. This cut is deepened carefully in order to allow the surgeon to gently separate the lining of the abdominal cavity from the underlying fatty tissue. When there is enough space, the mesh will be placed. Finally, the last step is to stitch the lining of the abdominal cavity back in place. The mesh distributes tension across the repaired area and is intended to both seal and strengthen the area to prevent future hernias. [15] Most hernias, including obturator hernias, have a strong rate of recurrence. After clinical intervention, mesh vs. non-mesh repair are two of the most common ways to finish the procedure. In a recent meta-analysis and systematic review of 1760 studies regarding obturator hernias, it was found that recurrence rates with mesh repair had a 31% chance of recurring, showing statistical significance with 95% confidence interval. However, mortality rates using mesh and non-mesh repair showed a non-significant 64% chance of mortality when compared across 11 studies and cases. [19]

Post-operative care

The road to recovery after surgical correction of an obturator hernia may vary from person to person depending on the severity of their hernia, any other simultaneous procedures done during surgery and individual hospital protocols. Although there are multiple different treatment approaches, many hospitals will follow their institution's guidelines for emergency hernia repair. [15] Post-surgery care for obturator hernias may also include protocols to aid in recovery of bowel resections as this is a procedure that may be performed in the process of treating the hernia but is not always necessary. Common post-operative approaches include bowel rest, pain management and wound care.

Bowel rest is a term often used by clinicians to describe a period that involves consumption of non-solid foods in order to give the digestive tract an opportunity to rest and recover. People on bowel rest may be asked to drink only clear liquids or to avoid consuming food and drink entirely. In the later case, nutrition will be provided by an intravenous line, often called an IV line.

Pain management is an important aspect to consider to help someone who has just undergone hernia repair. Keeping pain levels low encourages movement which may help speed up the healing process. The degree of pain a person may feel depends on the extent of their surgery. There is not an official guideline adopted across all hospitals for how to approach pain management in people who are recovering from hernia repair, however a search of different hospital protocols shows that over-the-counter pain relievers such as ibuprofen (commonly known as Advil or Motrin) and acetaminophen (Tylenol) are commonly recommended. [20] [21] Stronger pain relievers may also be prescribed by the medical team if it is necessary. In addition to medications, applying ice or heat may help to decrease pain.

Wound care is another topic that varies based on the situation. Specific instructions on how to care for a person's wound should be discussed during their post operation visit with their medical doctor.

Because of its rarity, there is no universal protocol on the timeline for follow-up visits for repair of an obturator hernia. When a person will come back for a follow-up appointment will depend on the clinical expertise of their surgical team. Often times people will be asked to return at 2 and 6 weeks after their surgery for the medical team to track the healing progress and help correct any pain or comfort issues. 

Related Research Articles

<span class="mw-page-title-main">General surgery</span> Medical specialty

General surgery is a surgical specialty that focuses on alimentary canal and abdominal contents including the esophagus, stomach, small intestine, large intestine, liver, pancreas, gallbladder, appendix and bile ducts, and often the thyroid gland. They also deal with diseases involving the skin, breast, soft tissue, trauma, peripheral artery disease and hernias and perform endoscopic as such as gastroscopy, colonoscopy and laparoscopic procedures.

<span class="mw-page-title-main">Laparoscopy</span> Minimally invasive operations within the abdominal or pelvic cavities

Laparoscopy is an operation performed in the abdomen or pelvis using small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.

<span class="mw-page-title-main">Appendicitis</span> Inflammation of the appendix

Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical symptoms. Severe complications of a ruptured appendix include widespread, painful inflammation of the inner lining of the abdominal wall and sepsis.

<span class="mw-page-title-main">Hernia</span> Abnormal exit of tissues or organs from the cavity they usually reside in

A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal development of the intestinal tract, referring to the retraction of the intestine from the extra-embryonal navel coelom into the abdomen in the healthy embryo at about 7½ weeks. Various types of hernias can occur, most commonly involving the abdomen, and specifically the groin. Groin hernias are most commonly inguinal hernias but may also be femoral hernias. Other types of hernias include hiatus, incisional, and umbilical hernias. Symptoms are present in about 66% of people with groin hernias. This may include pain or discomfort in the lower abdomen, especially with coughing, exercise, or urinating or defecating. Often, it gets worse throughout the day and improves when lying down. A bulge may appear at the site of hernia, that becomes larger when bending down. Groin hernias occur more often on the right than left side. The main concern is bowel strangulation, where the blood supply to part of the bowel is blocked. This usually produces severe pain and tenderness in the area. Hiatus, or hiatal hernias often result in heartburn but may also cause chest pain or pain while eating.

<span class="mw-page-title-main">Bowel obstruction</span> Medical condition

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, Is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.

<span class="mw-page-title-main">Diverticulitis</span> Digestive disease of the large intestine

Diverticulitis, also called colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—that can develop in the wall of the large intestine. Symptoms typically include lower-abdominal pain of sudden onset, but the onset may also occur over a few days. There may also be nausea; and diarrhea or constipation. Fever or blood in the stool suggests a complication. Repeated attacks may occur.

<span class="mw-page-title-main">Meckel's diverticulum</span> Medical condition

A Meckel's diverticulum, a true congenital diverticulum, is a slight bulge in the small intestine present at birth and a vestigial remnant of the vitelline duct. It is the most common malformation of the gastrointestinal tract and is present in approximately 2% of the population, with males more frequently experiencing symptoms.

<span class="mw-page-title-main">Inguinal hernia</span> Medical condition in which contents of the abdominal cavity protrude through the inguinal canal

An inguinal hernia or groin hernia, is a hernia (protrusion) of abdominal cavity contents through the inguinal canal. Symptoms, which may include pain or discomfort especially with or following coughing, exercise, or bowel movements, are absent in about a third of patients. Symptoms often get worse throughout the day and improve when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than left side. The main concern is strangulation, where the blood supply to part of the intestine is blocked. This usually produces severe pain and tenderness of the area.

Colic in horses is defined as abdominal pain, but it is a clinical symptom rather than a diagnosis. The term colic can encompass all forms of gastrointestinal conditions which cause pain as well as other causes of abdominal pain not involving the gastrointestinal tract. What makes it tricky is that different causes can manifest with similar signs of distress in the animal. Recognizing and understanding these signs is pivotal, as timely action can spell the difference between a brief moment of discomfort and a life-threatening situation. The most common forms of colic are gastrointestinal in nature and are most often related to colonic disturbance. There are a variety of different causes of colic, some of which can prove fatal without surgical intervention. Colic surgery is usually an expensive procedure as it is major abdominal surgery, often with intensive aftercare. Among domesticated horses, colic is the leading cause of premature death. The incidence of colic in the general horse population has been estimated between 4 and 10 percent over the course of the average lifespan. Clinical signs of colic generally require treatment by a veterinarian. The conditions that cause colic can become life-threatening in a short period of time.

<span class="mw-page-title-main">Umbilical hernia</span> Medical condition

An umbilical hernia is a health condition where the abdominal wall behind the navel is damaged. It may cause the navel to bulge outwards—the bulge consisting of abdominal fat from the greater omentum or occasionally parts of the small intestine. The bulge can often be pressed back through the hole in the abdominal wall, and may "pop out" when coughing or otherwise acting to increase intra-abdominal pressure. Treatment is surgical, and surgery may be performed for cosmetic as well as health-related reasons.

<span class="mw-page-title-main">Spigelian hernia</span> Surgical condition

A Spigelian is the type of ventral hernia where aponeurotic fascia pushes through a hole in the junction of the linea semilunaris and the arcuate line creating a bulge. It appears in the abdomen lower quadrant between an area of dense fibrous tissue and abdominal wall muscles causing a.

Femoral hernias occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness in the abdominal wall called the femoral canal. Femoral hernias are a relatively uncommon type, accounting for only 3% of all hernias. While femoral hernias can occur in both males and females, almost all develop in women due to the increased width of the female pelvis. Femoral hernias are more common in adults than in children. Those that do occur in children are more likely to be associated with a connective tissue disorder or with conditions that increase intra-abdominal pressure. Seventy percent of pediatric cases of femoral hernias occur in infants under the age of one.

An incisional hernia is a type of hernia caused by an incompletely-healed surgical wound. Since median incisions in the abdomen are frequent for abdominal exploratory surgery, ventral incisional hernias are often also classified as ventral hernias due to their location. Not all ventral hernias are from incisions, as some may be caused by other trauma or congenital problems.

<span class="mw-page-title-main">Bowel resection</span> Surgical procedure in which a part of an intestine is removed

A bowel resection or enterectomy is a surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often the word enterectomy is reserved for the sense of small bowel resection, in distinction from colectomy, which covers the sense of large bowel resection. Bowel resection may be performed to treat gastrointestinal cancer, bowel ischemia, necrosis, or obstruction due to scar tissue, volvulus, and hernias. Some patients require ileostomy or colostomy after this procedure as alternative means of excretion. Complications of the procedure may include anastomotic leak or dehiscence, hernias, or adhesions causing partial or complete bowel obstruction. Depending on which part and how much of the intestines are removed, there may be digestive and metabolic challenges afterward, such as short bowel syndrome.

Amyand's hernia is a rare form of an inguinal hernia which occurs when the appendix is included in the hernial sac and becomes incarcerated. The condition is an eponymous disease named after a French surgeon, Claudius Amyand (1660–1740), who performed the first successful appendectomy in 1735.

A paraumbilicalhernia is a hole in the connective tissue of the abdominal wall in the midline with close approximation to the umbilicus. If the hole is large enough there can be protrusion of the abdominal contents, including omental fat and/or bowel. These defects are usually congenital and are not noticed until they slowly enlarge over an individual's life time and abdominal contents herniate through the hole creating either pain or a visible lump on the abdominal wall. If abdominal contents get incarcerated in the hole this can cause pain. If the abdominal contents become strangulated by losing their blood supply from pinching or twisting those tissue will die. If it is omental fat this will cause pain and could potentially lead to an infection. If the strangulated contents are bowel then in addition to pain the individual will develop a bowel obstruction. And if the dead bowel is not surgically removed in an emergent fashion the condition could be fatal.

<span class="mw-page-title-main">Internal hernia</span>

Internal hernias occur when there is protrusion of an internal organ into a retroperitoneal fossa or a foramen in the abdominal cavity. If a loop of bowel passes through the mesenteric defect, that loop is at risk for incarceration, strangulation, or for becoming the lead point of a small bowel obstruction. Internal hernias can also trap adipose tissue (fat) and nerves. Unlike more common forms of hernias, the trapped tissue protrudes inward, rather than outward.

<span class="mw-page-title-main">Inguinal hernia surgery</span> Medical procedure

Inguinal hernia surgery is an operation to repair a weakness in the abdominal wall that abnormally allows abdominal contents to slip into a narrow tube called the inguinal canal in the groin region.

<span class="mw-page-title-main">Surgical mesh</span> Material used in surgery

Surgical mesh is a medical implant made of loosely woven mesh, which is used in surgery as either a permanent or temporary structural support for organs and other tissues. Surgical mesh can be made from both inorganic and biological materials and is used in a variety of surgeries, although hernia repair is the most common application. It can also be used for reconstructive work, such as in pelvic organ prolapse or to repair physical defects created by extensive resections or traumatic tissue loss.

References

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  2. 1 2 3 4 5 Schizas D, Apostolou K, Hasemaki N, Kanavidis P, Tsapralis D, Garmpis N, et al. (February 2021). "Obturator hernias: a systematic review of the literature". Hernia. 25 (1): 193–204. doi:10.1007/s10029-020-02282-8. PMID   32772276. S2CID   221070627.
  3. ↑ Losanoff JE, Richman BW, Jones JW (May 2002). "Obturator hernia". Journal of the American College of Surgeons. 194 (5): 657–663. doi:10.1016/S1072-7515(02)01137-7. PMID   12022607.
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  5. ↑ Chitrambalam TG, Christopher PJ, Sundaraj J, Selvamuthukumaran S (September 2020). "Diagnostic difficulties in obturator hernia: a rare case presentation and review of literature". BMJ Case Reports. 13 (9): e235644. doi:10.1136/bcr-2020-235644. PMC   7493113 . PMID   32933908. S2CID   221745984.
  6. ↑ Yamashita K, Hayashi J, Tsunoda T (June 2004). "Howship-Romberg sign caused by an obturator granuloma". American Journal of Surgery. 187 (6): 775–776. doi:10.1016/j.amjsurg.2003.10.020. PMID   15191874.
  7. ↑ Hannington-Kiff JG (January 1980). "Absent thigh adductor reflex in obturator hernia". Lancet. 1 (8161): 180. doi:10.1016/s0140-6736(80)90664-9. PMID   6101635. S2CID   3256825.
  8. 1 2 Nakayama T, Kobayashi S, Shiraishi K, Nishiumi T, Mori S, Isobe K, Furuta Y (September 2002). "Diagnosis and treatment of obturator hernia". The Keio Journal of Medicine. 51 (3): 129–132. doi: 10.2302/kjm.51.129 . PMID   12371643. S2CID   23526333.
  9. ↑ Mnari W, Hmida B, Maatouk M, Zrig A, Golli M (2019). "Strangulated obturator hernia: a case report with literature review". The Pan African Medical Journal. 32: 144. doi:10.11604/pamj.2019.32.144.14846. PMC   6607289 . PMID   31303916.
  10. ↑ Rizk TA, Deshmukh N (June 1990). "Obturator hernia: a difficult diagnosis". Southern Medical Journal. 83 (6): 709–712. doi:10.1097/00007611-199006000-00031. PMID   2192470.
  11. ↑ Park J (August 2020). "Obturator hernia: Clinical analysis of 11 patients and review of the literature". Medicine. 99 (34): e21701. doi:10.1097/MD.0000000000021701. PMC   7447413 . PMID   32846788.
  12. ↑ Cai X, Song X, Cai X (2012). "Strangulated intestinal obstruction secondary to a typical obturator hernia: a case report with literature review". International Journal of Medical Sciences. 9 (3): 213–215. doi:10.7150/ijms.3894. PMC   3298012 . PMID   22408570.
  13. ↑ Skandalakis LJ, Androulakis J, Colborn GL, Skandalakis JE (February 2000). "Obturator hernia. Embryology, anatomy, and surgical applications". The Surgical Clinics of North America. 80 (1): 71–84. doi:10.1016/s0039-6109(05)70398-4. PMID   10685145.
  14. ↑ Petrie A, Tubbs RS, Matusz P, Shaffer K, Loukas M (July 2011). "Obturator hernia: anatomy, embryology, diagnosis, and treatment". Clinical Anatomy. 24 (5): 562–569. doi:10.1002/ca.21097. PMID   21322061. S2CID   205536085.
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  17. ↑ Sze Li S, Kenneth Kher Ti V (January 2012). "Two different surgical approaches for strangulated obturator hernias". The Malaysian Journal of Medical Sciences. 19 (1): 69–72. PMC   3436498 . PMID   22977378.
  18. ↑ Petrie A, Tubbs RS, Matusz P, Shaffer K, Loukas M (July 2011). "Obturator hernia: anatomy, embryology, diagnosis, and treatment". Clinical Anatomy. 24 (5): 562–569. doi:10.1002/ca.21097. PMID   21322061. S2CID   205536085.
  19. ↑ Burla MM, Gomes CP, Calvi I, Oliveira ES, Hora DA, Mao RD, et al. (August 2023). "Management and outcomes of obturator hernias: a systematic review and meta-analysis". Hernia. 27 (4): 795–806. doi:10.1007/s10029-023-02808-w. PMID   37270718. S2CID   259064845.
  20. ↑ "Post-Surgery Hernia Pain | Information On Relief For Abdominal Pain After Hernia Surgery". University Hospitals. Retrieved 2023-07-30.
  21. ↑ "Post Operative Instructions: Hernias". University of North Carolina Health. July 29, 2023. Retrieved July 29, 2023.
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