Case report of ureter obturator hernia and literature review analysis.

BACKGROUND: Ureteral obturator hernia is a rare condition, usually found accidentally during imaging examinations, or found during surgery. Ureteral hernia can easily lead to ureteral obstruction and hydronephrosis. Long-term hydronephrosis may lead to kidney damage and infection, and eventually cause kidney failure. As of December 31, 2020, there are only 2 literature reports. CASE PRESENTATION: This article reports a 67-year-old female patient with no symptoms. The computed tomography (CT) scan of the urinary system to show the left kidney and ureter had hydrops. The CTU imaging of the urinary tract revealed the left ureter pelvis herniated into the parietal pelvic fascia was accompanied by tortuosity and left hydronephrosis. She underwent laparoscopic abdominal wall hernia repair on April 29, 2020, and she recovered well. CONCLUSIONS: Ureteral obturator hernia is an uncommon condition. The clinical symptoms are non-specific, including unclear abdominal pain, until the appearance of obstructive diseases of the urinary tract, such as renal insufficiency, urinary tract infection, kidney stones, and uremia. A comprehensive review of the literature shows that it is difficult to make an accurate diagnosis based on physical examination alone.Early urography can improve the possibility of accurate diagnosis. When a patient suffers from impaired renal function, timely surgical treatment can avoid deterioration of renal function.

Laparotomy with suture repair is the most common treatment for obturator hernia: a scoping review.

BACKGROUND: Obturator hernias are rare and associated with high mortality. However, the optimal surgical approach remains unknown. We aimed to investigate the available evidence and examine the surgical details regarding obturator hernia defect closure as well as the recurrence rates of the different approaches. METHODS: We reported this scoping review according to the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analysis Extension for Scoping Reviews) and registered the protocol online. A comprehensive literature search in five different databases was conducted. The population was patients undergoing surgery for obturator hernia. Articles were included for data charting if the management of the hernia defect was reported. Data regarding surgical details, and hernia recurrence were extracted. RESULTS: A total of 1299 patients from 313 articles were included. In total, 937 patients underwent open obturator hernia repair, in which 992 hernias were repaired (including some bilateral obturator hernias). A total of 295 patients underwent laparoscopic repair for 341 obturator hernias, and for the remaining 67 patients, type of surgery was not reported. For open surgery, suture repair was the most common method of repair (n = 508, 51%) with a recurrence rate of 10%. For laparoscopic surgery, the most common repair of the defect was mesh repair (n = 299, 88%) with no reported recurrences. CONCLUSION: Open surgery with primary suture repair is the most common method of repair for obturator hernia but is associated with a recurrence rate of 10%. Laparoscopic mesh repair is becoming more common and have seemingly very low recurrence rates and may be a better method of repair.

Diagnosis and treatment of obturator hernia: retrospective analysis of 86 clinical cases at a single institution.

BACKGROUND: To explore the clinical characteristics, diagnosis and treatment of obturator hernia. METHODS: Eighty-six patients who were diagnosed as obturator hernia by abdominal CT in the Department of Gastrointestinal Surgery of our hospital between 2009 and 2019 were enrolled in this study. Patient characteristics, surgical method, postoperative complications and mortalities were retrospectively reviewed. RESULTS: Thirty days mortality rate of 5.5% and 46.1% were observed in surgery group and non-surgery group, respectively. Surgery was performed as an emergency procedure in 59 cases and elective procedure in 14 cases depending on different hernia contents, intestinal necrosis and signs of peritonitis. In the emergency surgery group, segmental intestinal resection with anastomosis was performed in 24 patients (24/59, 40.7%). There were 4 deaths (4/59, 6.8%) in this group, all of which occurred in patients undergoing SI resections. In contrast, no bowel resection, postoperative complications, or death occurred in the elective surgery group. 3-year recurrence rates of 5.1% (3/59) and 7.1% (1/14) were observed in the emergency surgery and the elective surgery group, respectively. CONCLUSIONS: CT examination plays an important role in improving the diagnostic rate of obturator hernia. Timely surgical treatment is the key to improve the efficacy of obturator hernia and prevent the deterioration of the condition. In addition, intestinal resection and postoperative complications may be the important factors leading to postoperative death.

Treatment outcomes of Kugel repair for obturator hernias: a retrospective study.

BACKGROUND: We examined the validity and applicability of the Kugel repair approach for obturator hernias, whereby we placed a Kugel patch through the preperitoneal space after placing a short 5-cm skin incision just medial to the anterior iliac spine and 2 cm cranial to the expected origin of the internal inguinal ring. METHODS: We studied patients who underwent surgical Kugel repair for obturator hernias at the Department of General Surgery, Saitama Medical University between 2007 and 2017. We examined the operating time, length of hospital stay, postoperative complications, and mortality rate. RESULTS: Fifty-eight patients with obturator hernias presented with symptoms of small bowel obstruction. A Kugel approach was used in 53 patients and a midline approach was used in 5 patients with preoperative peritonitis. Of the 53 patients managed using the Kugel approach, 39 did not require intestinal resection; a mesh was used in all these patients. In the remaining 14 patients, intestinal resection was required and performed using the same approach; subsequently, a mesh was used successfully in 6 of these 14 patients. The overall median operating time was 47 min; the corresponding values for procedures with and without intestinal resection were 39 and 68 min, respectively. In terms of postoperative complications, operative mortality was not noted among patients without intestinal perforation; however, superficial surgical site infection developed in 2 patients. Among the 5 patients with preoperative peritonitis who underwent exploratory laparotomy via a midline incision, intestinal perforation was detected during surgery, and all patients required intestinal resection; none of the patients had received a mesh, and 2 patients died after surgery. CONCLUSIONS: The Kugel repair approach was possible even in patients with obturator hernia requiring intestinal resection. However, for patients with perforations, open surgery should be performed after securing the surgical field through a midline incision.

Obturator hernia presenting partial obstruction in an elderly patient.

Obturator hernia (OH) is a relatively rare pelvic hernia. OH is usually seen in elderly, multiparous females and patients with a low body weight. Obturator hernia accounts for 0.07-0.4% of all intraabdominal hernias and 0.2-5.8% of small bowel hernias. The diagnosis of obturator hernia can be difficult and often delayed. Any therapeutic delay is associated with serious complications and higher mortality rates. The correct preoperative diagnosis of obturator hernia is facilitated by computed tomography (CT). Our case was admitted to our emergency unit with intolerance to oral intake for one week. Abdominal ultrasonography was not helpful. The CT of the abdomen revealed the incarcerated intestinal segment. Diagnostic laparoscopy confirmed the CT findings. The intestine was gangrenous and perforated. Segmental resection and anastomosis was performed. Early diagnosis and surgical intervention are essential. This demonstrates that emergency CT scan is useful for the diagnosis of obturator hernia in patients presenting with mechanical intestinal obstruction of unknown origin.

[Staged bilateral total extraperitoneal allohernioplasty by e-TEP in a patient with recurrent oblique inguinal hernia on the left and combined strangulated femoral hernia on the right]. / Étapnaia dvustoronniaia total'naia ékstraperitoneal'naia allogernioplastika po metodike e-tep u patsienta s retsidivnoi kosoi pakhovoi gryzhei sleva i kombinirovannoi ushchemlennoi bedrennoi gryzhei sprava.

A case of two-stage minimally invasive surgical treatment of an elderly patient with bilateral inguinal hernia is presented: a recurrent oblique on the left, combined (femoral, obturator, oblique and direct inguinal) on the right with incarceration and necrosis of the small intestine in the femoral canal. Previously, the patient underwent closure of perforated ulcer of duodenum from upper-midline laparotomy, epicystostomy, transvesical adenomectomy from the lower-midline laparotomy. The first stage we performed diagnostic laparoscopy, minilaparotomy, reduction and resection of necrotic small intestine loop. The second stage was carried endovideoscopic total extraperitoneal allohernioplasty by the method of Extended-View Totally Extraperitoneal (e-TEP) on two sides. The positive results of the treatment indicate a high efficiency of video endoscopic alloplasty of occult hernias in a complex case. To diagnose and perform adequate surgical intervention with a combined femoral hernia, when the obturator and inguinal hernias are formed, but clinically do not manifest themselves, it is possible only with endoscopic examination of potential sites of hernia formation in the inguinal region, which is not possible with open plastic hernia of the inguinal region.

Lessons learned from an unusual condition of incidental synchronous multiple hernias of indirect inguinal hernia, femoral hernia, and incarcerated obturator hernia.

Hernias are one of the most common diseases. The frequency of multiple hernias is much higher than the frequency reported during herniorrhaphy. Multiple hernias may account for some of the so-called recurrences, in which the small hernia may be veiled by the bigger one and omitted. In this study, we present a case of an 83-year-old female who suffered from multiple hernias namely a left-sided indirect inguinal hernia, a right-sided femoral hernia, and a right-sided incarcerated obturator hernia. Additionally, the characteristics and treatment of obturator hernia were discussed. Ultrasound and computed tomography (CT) are capable of accurately diagnosing groin hernia. Preoperative bilateral ultrasound of examinations or abdominopelvic CT should be recommended to perform routinely for patients with suspected hernias to avoid ignoring the concurrent hernias. A careful exploration of the operative field in the operation is mandatory. The CT is also helpful for early diagnosis of obturator hernia. In addition, the intra-abdominal approach through a low midline incision might be a preference for the treatment of obturator hernia.

Ultrasound-guided reduction of an incarcerated obturator hernia in an elderly patient.

Obturator hernia is a rare but clinically relevant cause of intestinal obstruction, usually found in elderly, thin, multiparous women. It is difficult to diagnose, leading to diagnostic delay with a high incidence of strangulation and a high mortality rate. Surgery is the only reported treatment. We report the case of an 86-year-old woman, in whom an early diagnosis of incarcerated obturator hernia was made with subsequent reduction by compression with an ultrasound transducer. When the risk of strangulation is presumed to be low, ultrasound-guided reduction of an obturator hernia is achievable and worth considering.

Efficacy of emergency exploratory laparotomy in incarcerated obturator hernia.

BACKGROUND: Incarcerated obturator hernia (IOH) is a scarce type of acute surgical disease, but the mortality rate is the highest in abdominal hernias. The aim of this study was to evaluate the efficacy of emergency exploratory laparotomy (EEL) in treating incarcerated obturator hernia (IOH). METHODS: We conducted a retrospective study of 12 female patients with IOH underwent EEL between January 2014 and March 2016. The variables which included patient characteristics, findings of CT, operative time, postoperative complications, length of hospital stay, ICU admission rate, 30-day readmission rate and mortality were analyzed. RESULTS: The age of patients was 82.5 ± 4.2 years and the median body mass index (BMI) was 20.6 kg/m2 (IQR, 18.7-21.5 kg/m2). There were 10 patients (83.3%) underwent partial intestinal resection due to partial small bowel necrosis or perforation. The total operation time was 85.7 ± 8.7 min. The time to initiation of a soft diet was 3.9 ± 0.7 days and the median length of stay was 15.0 days (IQR, 14.0-17.5 days), respectively. CONCLUSIONS: The EEL is a clinically safe and necessary choice for early diagnosis and treatment in IOH. EEL may improve the curative effect of IOH significantly.

The feasibility of laparoscopic management of incarcerated obturator hernia.

BACKGROUND: Obturator hernia (OH), a rare cause of acute small bowel obstruction, requires immediate surgical intervention to prevent serious complications and mortality. We assessed the safety and efficacy of laparoscopic surgery in patients with incarcerated OH presenting with acute abdomen in an emergency setting. METHODS: Data pertaining to patients diagnosed with incarcerated OH between 2011 and April 2015 at our hospital were reviewed. Patients' characteristics, operation details and postoperative outcomes were retrospectively analyzed. RESULTS: All ten patients diagnosed with incarcerated obturator hernia during the reference period were females (average age 72.1 ± 11.8 years; average weight 44.1 ± 6.9 kg; average body mass index 17.8 ± 2.1 kg/m2; average operating time 63 ± 15 min; average hospital stay 6.2 ± 6.6 days). Twelve occult hernias, including six contralateral OHs, two ipsilateral femoral hernias and two bilateral femoral hernias were detected in six patients (60 %), which were simultaneously repaired after laparoscopic exploration. Nine patients (90 %) were successfully treated with synthetic mesh by laparoscopic technique. Only one case required intraoperative conversion to open surgery due to strangulated intestine with perforation. Wound infection was reported in one patient who had undergone bowel resection, but with an eventual complete recovery. Postoperative period was uneventful in the other nine patients. No recurrence or complications were reported on follow-up (mean duration of follow-up: 6-54 months). CONCLUSION: In this study, laparoscopic technique was associated with a reduced duration of hospital stay and fewer complications. In addition to being a safe and minimally invasive strategy, it allowed for simultaneous diagnosis and treatment of occult hernias during the same procedure. The approach may be a better option for the treatment of incarcerated OH and occult hernias in selected patients.

Obturator Hernia, 'The Little Old Lady Hernia'.

Obturator hernia is a rare type of abdominal hernia that classically presents in elderly women. We report the case of 78-year-old woman with progressive vomiting, obstipation, and abdominal pain. Contrast-enhanced computed tomography showed a left-sided obturator hernia, which was confirmed and treated at laparotomy. Demographics, symptoms, imaging findings, and management of obturator hernias is reviewed.

Obturator hernia: An uncommon cause of small bowel obstruction.

A 70 year old lady presented to surgery emergency with small bowel obstruction without any obvious etiology. On exploration she was found to have an obstructed obturator hernia, which is a rare pelvic hernia with an incidence of 0.07-1.4% of all intra-abdominal hernias. Diagnosis is often delayed until laparotomy for bowel obstruction. Strangulation is frequent and mortality remains high (25%). Early diagnosis and surgical treatment contributes greatly to reduce the mortality and morbidity rates. A variety of techniques have been described, however surgical repair has not been standardized. It is an important diagnosis to be considered in elderly patients with intestinal obstruction.

Computed tomography in the investigation and management of obturator hernia.

INTRODUCTION: Obturator hernias are a rare groin hernia. They are most commonly found incidentally during laparoscopic inguinal hernia repair. We investigated our experience with obturator hernias in the elective and emergency setting. METHODS: Cases of obturator hernia were identified from a hospital database and reviewed retrospectively over the last 10 years. There were no exclusions. There were a number of surgeons involved with an interest in groin hernia surgery. RESULTS: Twenty-one patients were included. The mean age was 66 years old. Eleven were male. There were four emergency presentations. One emergency case presented with small bowel obstruction, while the other three cases presented with groin pain. Two patients had a preoperative computed tomography, which showed an obturator hernia confirmed at surgery. The patient with small bowel obstruction had an open bowel resection alone with no hernia repair. They were discharged with no complications or recurrence on follow-up. The other three cases had a mesh repair (one laparoscopic, one laparotomy, one pre-peritoneal). One patient who underwent a laparotomy died of a post-operative pneumonia. The others were discharged uneventfully. In the elective group of 17 patients, 8 patients were taken for an elective laparoscopic inguinal hernia repair but found to actually have an obturator hernia alone. An obturator hernia was found incidentally with an inguinal hernia in three patients. Five patients were expected to have an obturator hernia on clinical examination alone. At surgery, an obturator hernia was found in three cases. In the other two cases, no hernia was found. One patient had a pre-operative computed tomography, which showed an obturator hernia confirmed at surgery. CONCLUSIONS: Computed tomography would be recommended in cases of diagnostic uncertainty. It may avoid unnecessary surgery in the elective setting and allow a focused procedure in the emergency setting. Laparoscopic repair is feasible in the emergency and elective setting with excellent results.

Coexisting incarcerated femoral and obturator hernia: a case report.

BACKGROUND: Obturator hernia is a rare condition associated with a high morbidity and mortality. It is an uncommon cause of bowel obstruction most commonly described in elderly females with comorbidity. Surgical intervention is often delayed as a result of subtle presenting signs. Coexisting ipsilateral femoral hernia is an even rarer condition represented by non-exhaustive series in the literature. CASE PRESENTATION: We report a case of a healthy 36 years old lady, nulliparous, with abdominal pain and swelling in the right groin. Preoperative CT showed only a right groin hernia, that was found to be femoral at operative intervention. She recovered and was discharged from hospital but represented with further symptoms of obstruction 9 days later. Diagnostic laparoscopy demonstrated a ipsilateral obturator hernia with associated bowel infarct. The bowel was resected and the defect was repaired. DISCUSSION AND CONCLUSIONS: Obturator hernia presents subtly with medial thigh pain and no lump. They are notorious for difficulty to diagnosis. We describe the first case of coexisting ipsilateral femoral and obturator hernias in a young nulliparous woman with bowel obstruction. Appropriate intraoperative exploration should always be considered.

A case of a perforated obturator hernia with a femoral abscess treated a pectineus muscle flap.

BACKGROUND: An obturator hernia accompanied with a femoral abscess is rare, and leads to severe infection. Repeated draining is often required due to remnant abscess. CASE PRESENTATION: We herein reported a case of a perforated obturator hernia with a femoral abscess that was successfully treated via repair using the pectineus muscle. An 84-year-old Japanese woman was referred to our hospital with appetite loss and right femoral pain. Abdominal computed tomography (CT) revealed a right obturator hernia and abscess spreading to the right thigh. Emergency surgery was performed. Intraoperative findings revealed that the abscess had formed because of a perforation in the small intestine by an incarcerated obturator hernia. We performed partial resection of the small intestine, repaired the hernial orifice, drained the right femoral abscess, and filled the cavity using the pectineus muscle. A residual abscess was not detectable following surgery, and the patient was discharged on postoperative day 63. CONCLUSION: Some patients with a perforated obturator hernia and femoral abscess have a residual abscess following surgery that requires redrainage. Nevertheless, we consider it possible to successfully treat a perforated obturator hernia with a femoral abscess via repair using the pectineus muscle.

Sciatic hernia: is it really rare?

PURPOSE: It is generally believed that sciatic hernia is extremely rare; however, asymptomatic sciatic hernia is occasionally found in patients with an obturator hernia. We investigated the frequency, risk factors, and prognosis of asymptomatic sciatic hernia, which have never been discussed in a published report. METHODS: We retrospectively reviewed multidetector-row computed tomography (MDCT) images of 38 consecutive cases of new-onset obturator hernia. The co-existence of sciatic hernia was diagnosed from the MDCT findings of some of these patients. The clinical characteristics and clinical courses were compared between the sciatic hernia group and the non-sciatic hernia group. RESULTS: Nine patients (24 %) had concomitant asymptomatic sciatic hernias, five (13 %) of which were bilateral.The body mass index (BMI) was significantly lower in the patients with a concomitant sciatic hernia (17.2 ± 2.4 kg/m(2)) than in those without a sciatic hernia (19.6 ± 2.6 kg/m(2); P = 0.02). All patients received treatment for incarcerated obturator hernias, but none underwent repair of the concomitant sciatic hernia because all were non-incarcerated and asymptomatic. None of the patients has had trouble with their untreated sciatic hernia after the obturator hernia treatment. CONCLUSIONS: Up to 24 % of these obturator hernia patients had a concomitant sciatic hernia. A low BMI was a risk factor for concomitant sciatic hernia. Immediate surgical repair of the sciatic hernia may not be needed, unless it is symptomatic.

Laparoscopic trans-peritoneal hernioplasty (TAPP) is useful for obturator hernias: report of a case.

A 71-year-old female presented to our hospital due to pain from the right hip joint to the lower abdomen. The pain had suddenly appeared and spontaneously disappeared more than 10 times during the past 2 years. She had visited many hospitals, but remained undiagnosed. The patient underwent a computed tomography (CT) scan of the pelvis, and a soft tissue shadow was seen between the external obturator and pectineal muscles. She was diagnosed with a right obturator hernia and underwent elective repair by laparoscopic trans-peritoneal hernioplasty (TAPP). 1 year has passed since the surgery, without any recurrence of the abdominal pain. Obturator hernias are rare, and most cases are found as incarcerated hernias. It is rare to find an obturator hernia without intestinal obstruction, or with the recurrent pain as in our case. We herein report a case in which an obturator hernia was undiagnosed and intermittent pain was experienced for 2 years prior to TAPP, which appears to have successfully treated the hernia.