Midline Extraperitoneal Approach for Obturator Hernia Repair

Abstract

Obturator hernia (OH) is a rare condition that accounts for 0.073-1% of abdominal hernias and 0.48% of bowel obstructions. OH frequently occurs in elderly women, with an incidence that increases with age. The only treatment for OH is surgical intervention, and the approaches used vary greatly. Consequently, a well-defined consensus has not yet emerged. We assessed the efficiency and safety of the midline extraperitoneal approach for OH. Six patients with OH repaired using the midline extraperitoneal approach at KKR Sapporo Medical Center between April 2011 and January 2016 were included in the study. We retrospectively evaluated the patient characteristics, intraoperative findings, and the postoperative course. All patients were elderly women [median age, 90 (range, 79-92) years], with a median body mass index of 17.0 (range, 15.6-18.3) kg/m 2 at presentation. All had symptoms associated with bowel obstruction: two patients presenting with leg pain had the Howship-Romberg sign. In two patients, bowel resection was required because of irreversible ischemic changes. Five patients had coexisting femoral and inguinal hernias that were repaired by bilateral mesh repair. One patient had aspiration pneumonia as a postoperative complication. All patients were discharged alive, without infection or recurrence. OH can be efficiently and safely repaired using the midline extraperitoneal approach. This approach establishes the diagnosis of OH, avoids injuring obturator vessels, gives improved exposure of the obturator canal, enables identification and simultaneous repair of other pelvic hernias, and facilitates bowel resection. This approach reduces the risk of mesh infection in patients undergoing bowel resection.

Concurrent strangulated obturator hernia and femoral hernia repair via TAPP approach: A case report

“…The image of the bowel herniating through the obturator foramen and lying between the pectineus muscle anteriorly and the obturator externus muscle posteriorly is diagnostic. 13,15 In our patient, the protrusion of the bowel through the obturator foramen was observed on CT, and the definitive diagnosis of OH was constituted (Figure 1).…”

Mechanical intestinal obstruction in underweight, elderly women due to an incarcerated obturator hernia

“…Other approaches are described, which should be conducted by experienced surgeons only. 16,17 We consider that in the case of acute bowel obstruction, transperitoneal surgery is commonly used and will, therefore, be conducted with minimal complications. Laparoscopy, on the other hand, is becoming increasingly popular with a higher number of OH cases being corrected using this minimallyinvasive procedure.…”

“…Using this approach, the surgeon can confirm diagnosis, circumvent obturator vessels, establish proper visualization of the obturator ring and facilitate bowel resection if needed. Other approaches are described, which should be conducted by experienced surgeons only 16,17 . We consider that in the case of acute bowel obstruction, transperitoneal surgery is commonly used and will, therefore, be conducted with minimal complications.…”

Rare Case of Peritonitis due to Ileal Perforation Secondary to Richter’s Type of Obturator Hernia

“…The only possible treatment is surgical treatment, which can be through either laparotomy or laparoscopy, with repair of obturator canal either with omentum, mesh or sutures. The abdominal approach is often favored, although the laparoscopic approach has shown to have fewer complications [9]. The abdominal, low midline approach favors the identification of hernia and resection of gangrenous bowel if necessary.…”