Surgery

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Case Report
Intestinal obstruction due to an obturator hernia:
a case report with a review of the literature
Z Antoniou1*, E Volakaki1, E Giannakos1, DC Kostopoulos2, A Chalazonitis1

Introduction
Obturator hernia is a rare abdominal
hernia and a diagnostic challenge. It is
a significant cause of intestinal obstruction in thin, elderly women. Delayed
diagnosis and surgical intervention causes its high morbidity and mortality. Computed tomography is a valuable
tool for preoperative diagnosis. This report presents an Intestinal obstruction due to an obturator hernia.
Case report
This report presents the case of an 84year-old female patient with a small
bowel obstruction caused due to an
obturator hernia.
Conclusion
A computed tomography scan is valuable to establish preoperative diagnosis. Early diagnosis and surgical treatment contribute greatly to reduce the
morbidity and mortality rate.

Introduction

Obturator hernia was first described

by Arnaud de Ronsil. It is considered
to be rare and accounts for 0.05%
0.4% off all hernias1 and 0.2%1.6%
of all cases of mechanical intestinal
obstruction2. It is more common
in thin, elderly females and has a
high mortality rate between 13%
and 40%3. Rapid evaluation and
early surgical intervention can
reduce morbidity and mortality. A
computed tomography (CT) scan of
the pelvis and upper thigh is the best
imaging tool in obturator hernia.
This report discusses an intestinal

* Corresponding author
Email: zantoniou84@hotmail.com
1

Radiology Department, Alexandra General

Hospital, Athens, Greece
Medical School, University of Athens, Greece

obstruction caused in a patient due

to an obturator hernia.

Case report
An 84-year-old female was admitted
to our hospital with colicky abdominal pain and repeated episodes of
vomiting. Pain was localised over
the periumbical area and radiated
along the medial side of the thigh. On
physical examination, the patients
vital signs were stable, her abdomen
was distended centrally and abdominal tenderness was present with
no evidence of peritonitis or free
fluid. There were hyperactive bowel
sounds. No abnormal signs were
found on rectal and vaginal examinations. Biochemical parameters
were within normal limits. Plain
abdominal radiography revealed
multiple distended bowel loops. A
CT scan and reconstruction of the
acquired images in coronal and axial
planes was performed to determine the cause of bowel obstruction
(Figure 1). The CT scan demonstrated dilated fluid-filled loops of
small bowel up to a herniated loop of
small bowel, through the obturator
canal (Figure 2). Small bowel loop
was noted between the pectineus and
the left external obturator muscle
(Figure 3). Obturator hernia was
diagnosed and emergency surgical
treatment was arranged.

Figure 1: CT scout demonstrating

multiple dilated small bowel loops.

Figure 2: CT scan demonstrating

mechanical small bowel obstruction:
multiple dilated fluid-filled small
bowel loops (red arrow) and normalsized, small bowel loops distal to the
hernia (green arrow).

Discussion
Obturator hernia proceeds through
the obturator foramen situated bilaterally in the anterolateral pelvic
wall, interiorly to the acetabulum.
The obturator artery, vein and nerve
pass through this tunnel protected by
extraperitoneal connective tissue and
fat4,5. Typically, obturator hernias occur
in elderly women or patients with
chronically raised intra-abdominal

Figure 3: CT scan demonstrating

a small bowel loop between the
pectineus and the left external
obturator muscle (red arrow).

Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY)

F
: Antoniou Z, Volakaki E, Giannakos E, Kostopoulos DC, Chalazonitis A. Intestinal obstruction due
to an obturator hernia: a case report with a review of the literature. OA Case Reports 2013 Jan 31;2(1):5.

Compeng interests: none declared. Conflict of Interests: none declared.

All authors contributed to the concepon, design, and preparaon of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Associaon for Medical Ethics (AME) ethical rules of disclosure.

Abstract

Page 2 of 2

Case Report
better delineate the size and shape
of the hernia sac and associated
complications3. Intravenous administration of contrast medium helps
check the vascular supply of the
bowel wall to detect complications
such as ischemia. Dilation of small
bowel proximal to the hernia is a
sign of obstructed hernia. The intraabdominal approach through a low
midline incision is most commonly
used as it can establish the diagnosis,
avoid the obturator vessels, expose
the obturator ring and facilitate
bowel resection if necessary9. Retropublic, preperitoneal, groin or laparoscopic approaches may be used if
the diagnosis is made preoperatively.

Conclusion
Obturator hernia remains an important diagnosis to consider in elderly
patients with intestinal obstruction.
CT scan is valuable to establish preoperative diagnosis. Early diagnosis
and surgical treatment contribute
greatly to reduce the morbidity and
mortality rate.

Abbreviations list
CT, computed tomography.

Consent
Written informed consent was
obtained from the patient for publication of this case report and accompanying images. A copy of the written
consent is available for review by the
Editor-in-Chief of this journal.

References
1. Skandalakis LJ, Skandalakis PN, Gray
SW, Skandalakis JE. Obturator hernia. In:
Nyhus LM, Condon RE, editors. Hernia.
4th ed. PhiIadelphia: J.B. Lippincott Co;
1995.p42539.
2. Thanapaisan C, Thanapaisal C. Sixty-one
cases of obturator hernia in Chiangrai
Regional Hospital: retrospective study. J
Med Assoc Thai. 2006 Dec;89(12):20815.
3. Aguirre D, Santosa A, Casola G, Sirlin C.
Abdominal wall hernias: imaging features,
complications, and diagnostic pitfalls at
multi-detector row CT. Radiographics.
2005 NovDec;25(6):150120.
4. Whiteside JL, Walters MD. Anatomy of
the obturator region: relations to a transobturator sling. Int Urogynecol J Pelvic
Floor Dysfunct. 2004 JulAug;15(4):2236.
5. Hsu CH, Wang CC, Jeng LB, Chen MF.
Obturator hernia: a report of eight cases.
Am Surg. 1993 Nov;59(11):70911.
6. Cai X, Song X, Cai X. Strangulated intestinal obstruction secondary to a typical
obturator hernia: a case report with
literature review. Int J Med Sci. 2012
Mar;9(3):2135.
7. De Clercq L, Coenegrachts K, Feryn T,
Van Couter A, Vandevoorde R, Verstraete K,
et al. An elderly woman with obstructed
obturator hernia: a less common variety
of external abdominal hernia. JBR-BTR.
2010 NovDec;93(6):3024.
8. Hannington-Kiff JG. Absent thigh
adductor reflex in obturator hernia.
Lancet. 1980 Jan;1(8161):180.
9. Nakayama T, Kobayashi S, Shiraishi K,
Nishiumi T, Mori S, Isobe K, et al. Diagnosis and treatment of obturator hernia.
Keio J Med. 2002 Sep;51(3):12932.

Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY)

F
: Antoniou Z, Volakaki E, Giannakos E, Kostopoulos DC, Chalazonitis A. Intestinal obstruction due
to an obturator hernia: a case report with a review of the literature. OA Case Reports 2013 Jan 31;2(1):5.

Compeng interests: none declared. Conflict of interests: none declared.

All authors contributed to the concepon, design, and preparaon of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Associaon for Medical Ethics (AME) ethical rules of disclosure.

pressure. The female predominance of these hernias is the result

of pregnancy, which leads to relaxation of the pelvic peritoneum and
a wider and more horizontal obturator canal5. In general, obturator
hernias are asymptomatic unless
the hernia sac compresses the obturator nerve and produces the pathognomonic HowshipRomberg sign,
which includes pain with or without
paresthaesia localised down the
anteromedial thigh to the knee upon
movement of the hip or thigh.
The HowshipRomberg sign is
positive in 15%50% of cases6,7. The
HanningtonKiff sign, a clinical sign
in which there is an absent adductor
reflux in the thigh, is more specific
but less known6,8. Other symptoms
include acute or intermittent small
bowel obstruction with high risk of
strangulation, weight loss and rarely
a palpable mass6,7. Various imaging
examinations such as ultrasonography, herniography and CT scan
have been applied to establish the
diagnosis. The best imaging tool is
CT which has superior sensitivity
and accuracy6,7. Bowel herniating
through the obturator foramen and
lying between the pectineus and
obturator muscles is a key finding
on CT and determines the diagnosis7.
CT also differentiates the obturator hernia from other abdominal
masses, such as tumours, haematomas and abscesses. Thin, reformatted images of 2.5 mm or less may