https://orcid.org/0000-0002-0533-5833
Abstract
Obturator hernia is a rare cause of bowel obstruction that predominantly affects elderly, thin women. Because clinical manifestations are often nonspecific, diagnosis is frequently delayed, leading to increased morbidity and mortality. We report the case of an 89-year-old woman who presented with acute pelvic pain radiating to the right lower limb and bilious vomiting. Contrast-enhanced computed tomography (CT) revealed a right-sided incarcerated obturator hernia involving the small bowel, with associated signs of bowel obstruction and suspected ischaemia. The patient underwent emergency surgery with a favourable postoperative outcome. Obturator hernia remains a diagnostic challenge because of its rarity and nonspecific clinical presentation. CT is the imaging modality of choice for establishing the preoperative diagnosis, assessing bowel viability, and guiding surgical management. Early recognition and prompt surgical intervention are essential to prevent strangulation and bowel necrosis. Obturator hernia should therefore be considered in the differential diagnosis of bowel obstruction in elderly women, as timely imaging and surgical treatment are crucial for improving patient outcomes.
Introduction
Obturator hernia is a rare cause of bowel obstruction, accounting for less than 1% of abdominal wall hernias. Diagnosis is often challenging because clinical manifestations are nonspecific, contributing to high morbidity and mortality. The condition predominantly affects elderly, thin women due to anatomical and age-related changes that increase the risk of herniation. Common symptoms include abdominal pain, nausea, and vomiting, while the Howship–Romberg sign, caused by obturator nerve compression, is characteristic but infrequently observed. Incarcerated obturator hernia requires prompt surgical management, with the operative approach tailored to the patient’s condition and surgical expertise [1, 2].
Furthermore, the narrow anatomy of the obturator canal predisposes obturator hernias to incarceration and strangulation, increasing the risk of bowel ischaemia and necrosis. As clinical findings are frequently subtle, diagnosis is often delayed; therefore, computed tomography (CT) plays a pivotal role in early detection and in evaluating intestinal viability, guiding timely surgical management [3–5].
We report a case of incarcerated obturator hernia causing small bowel obstruction in an 89-year-old woman.
Case presentation
An 89-year-old woman with a medical history of hypertension, dyslipidemia, glaucoma, and colonic diverticulosis presented to the Emergency Department with acute pelvic pain radiating to the right lower extremity that had developed a few hours earlier. She also reported two episodes of bilious vomiting, one occurring at home and a second after arrival at the hospital.
A contrast-enhanced abdominal CT scan demonstrated a right obturator hernia measuring approximately 35 × 27 mm, protruding through a 12-mm obturator foramen defect (Fig. 1). The hernia sac contained an incarcerated small bowel loop located between the pectineus and adductor muscles. The involved bowel segment showed wall thickening, reduced enhancement, surrounding fluid, and inflammatory changes of the adjacent fatty tissue, raising suspicion of bowel ischaemia. Proximal small bowel dilatation (maximum diameter 28 mm) with multiple air–fluid levels was also observed, consistent with mechanical small bowel obstruction.
CT scan image.
Based on the radiological findings of an incarcerated obturator hernia with suspected bowel compromise, the patient was scheduled for emergency exploratory laparoscopy. Her past surgical history was notable for a previous orthopaedic procedure with metallic screw fixation of the right humeral head.
The procedure was performed laparoscopically under general anaesthesia. Pneumoperitoneum was established using the open Hasson technique through a 12-mm umbilical camera trocar, followed by placement of 5 mm additional trocars in right and left flank. The incarcerated bowel loop was identified and carefully reduced. Bowel integrity and vascularization were assessed using indocyanine green fluorescence imaging, confirming adequate perfusion. A tailored Parietex™ mesh was then positioned and secured with interrupted polypropylene (Prolene®) sutures. Haemostasis was verified, and no intraoperative complications occurred.
The postoperative course was uneventful. Oral feeding was resumed 12 h postoperatively, and the patient was discharged on postoperative day 3. At follow-up, the patient was in good clinical condition, with no evidence of postoperative complications.
Discussion
Obturator hernia is a rare but potentially life-threatening pelvic hernia and an uncommon cause of small bowel obstruction, predominantly affecting thin, frail, elderly women [3, 6]. Its diagnosis remains challenging because of the nonspecific clinical presentation and the absence of characteristic physical findings, often resulting in delayed recognition [6, 7]. Therefore, obturator hernia should always be considered in the differential diagnosis of bowel obstruction in elderly women, even in the absence of previous abdominal surgery [2]. Contrast-enhanced CT is the diagnostic modality of choice, although radiological signs may be subtle and require careful interpretation; in some cases, the definitive diagnosis is established intraoperatively [2, 7]. Early diagnosis and prompt surgical management are crucial to prevent bowel strangulation, intestinal necrosis, and other severe complications, thereby reducing the high morbidity and mortality associated with this condition [2, 3, 6]. Furthermore, the length of the incarcerated bowel segment on CT may represent a potential predictor of intestinal necrosis in patients with obturator hernia [5]. Our case highlights the importance of maintaining a high index of suspicion and the key role of CT imaging in achieving timely diagnosis and treatment [8].
Conclusion
Obturator hernia is a rare but serious cause of bowel obstruction in elderly women and should be suspected even without prior abdominal surgery. Due to its nonspecific presentation, early CT diagnosis and prompt surgical management are essential to prevent bowel ischaemia and reduce morbidity and mortality.
Conflicts of interest
None declared.
Funding
None declared.
