'Little old lady's hernia' (obturator hernia): A deceptive encounter.

Obturator hernia (OH) is rare which not only carries high mortality amongst all abdominal hernia, but also known for the difficulty in diagnosing it. Howship-Romberg sign is a clinical sign to diagnose OH, but due to the lower-limb muscle contractures, it was not possible in our case. Computed tomography scan becomes the investigation of choice in this situation. A laparoscopic approach can be used safely.

DESCRIPTION

A 77-year-old female presented with colicky pain in abdomen, constipation and two episodes of bilious vomiting associated with distension of abdomen for 3 days. Due to poor nutrition and suboptimal post-hemiparesis rehabilitation, she had developed muscular contractures of both the lower extremities. She was haemodynamically stable with tense generalised distended abdomen without tenderness or guarding with hyperperistalsis on auscultation. Inguinal, perineal and digital rectal examinations were within normal limit.

Abdominal radiograph showed multiple air-fluid levels in the small bowel, suggestive of obstruction at the level of small bowel.

Contrast-enhanced computed tomography (CECT) was done which revealed a dilated jejunum and ileum with maximum diameter of 3 cm along with few collapsed distal ileal loops. The zone of transition was seen near the left-sided obturator canal, and the loop of ileum was seen herniating out of the obturator canal between pectineus and obturator externus muscles [Figures 1 and 2].

Figure 1

Computed tomography showing obturator hernia: Ileal loop protruding out of the obturator canal from the left side, between pectineus and obturator externus muscles

Figure 2

Intraoperative laparoscopic view of a left-sided obturator hernia showing hernial neck borders over the obturator canal

We did an emergency laparoscopic hernia repair; intraoperatively, small bowel was distended and a loop of mid-ileal segment was seen herniating through the left obturator foramen [Figure 1]. Reduction of hernia was done and the defect in the obturator canal via the obturator externus muscle was visible [Figure 2], which was then closed internally with interrupted non-absorbable prolene sutures.

Obturator hernia (OH), also known by a nickname ‘little old lady's hernia’, should be considered in as a cause of obstruction, especially in female geriatric patients where it can carry a high mortality as compared to all abdominal hernias.[12] The clinical test to diagnose OH is Howship–Romberg sign (inner thigh pain on internal rotation of the hip). OH was difficult to diagnose in our case because it was not possible to elicit Howship–Romberg sign due to restricted limb movements because of contractures.

Hernia is the second cause of intestinal obstruction after adhesive obstruction; hence, detailed history and physical examination and all attempts should be made to rule out the same. External swelling/lump is not seen in many patients (also in our case); hence, a CECT scan is the investigation of choice in such cases. CECT also gives a global picture of the abdomen and also gives details related to bowel viability which can help in planning the best possible surgical approach. Laparoscopic or minimally invasive surgical approach is one of the best optimal healthcare goals for early recovery, reduced hospital stay and less complication in many situations where expertise is available.

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Conflicts of interest

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