Strangulated obturator hernia with ischaemic and perforated small bowel

Obturator hernia is rare, but it must be considered in elderly patients who present with small bowel obstruction. The diagnosis is challenging unless there is a high index of suspicion as the presenting symptoms and signs are usually non-specific. Presence of positive Howship-Romberg sign is considered pathognomonic. Early diagnosis and rapid surgical intervention will reduce the high morbidity and mortality associated with undiagnosed obturator hernia. We report a case of a 93-year-old female patient who was admitted to our surgical department with symptoms of intestinal obstruction of 3-days duration. Howship-Romberg sign was negative. Computed tomography (CT) demonstrated the presence of left obturator hernia with proximal small bowel obstruction and no sign of strangulation. The patient had emergency laparotomy post-CT where the incarcerated bowel loop was released and the obstructed bowel was decompressed without any complication. The hernial defect was close with a mesh and the patient had an uneventful recovery post-surgery. In this case, we highlight that diagnosis of obturator hernia must always be considered in elderly patients who present with intestinal obstruction. Urgent CT could establish a rapid pre-operative diagnosis and aids inappropriate surgical intervention planning which is crucial in optimising the outcome.

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248 Rectus flap for repair of Strangulated Obturator Hernia

British Journal of Surgery ◽

10.1093/bjs/znab259.278 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

N Angamuthu ◽

S Alagaratnam ◽

M Varcada ◽

R D'Souza

Keyword(s):

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Primary Anastomosis ◽

Muscle Flap ◽

Rectus Muscle ◽

Obturator Hernia ◽

Suture Repair ◽

Primary Suture ◽

Large Defect

Abstract Introduction Obturator hernia (OH) is a rare abdominal wall hernia which commonly presents as small bowel obstruction. Surgical options include suture repair or use of autologous tissue or a mesh repair when primary suture repair is not feasible. We describe a case involving the use of the rectus abdominus muscle to repair a large OH. Case report An 81-year-old female presented with three days of abdominal distension and vomiting. A computerised tomography scan confirmed small bowel obstruction due to an obstructed left OH. At laparotomy, a short segment of non-viable distal ileum was reduced from the sac and resected with a primary anastomosis. The obturator defect was not amenable for suture approximation and due to concerns of possible mesh infection, the ipsilateral rectus muscle belly was mobilised from the anterior sheath, routed extra-peritoneally to plug the defect without tension. The muscle was anchored with prolene sutures to the cooper’s ligament, pectineus muscle and the fascia overlying the inner surface of inferior pubic ramus. Four months post-operatively, she has made an excellent recovery with no concerns currently. Conclusions In OH with a large defect precluding primary suture repair, a range of options have been described (use of autogenous peritoneal fold, pectineus muscle, round ligament, ovary, uterine fundus, omental and mesh plugs, and biological mesh). We believe, to plug and cover the defect, rectus muscle flap is a viable option giving a tension free robust repair, especially in patients with gangrenous bowel and local contamination.

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