292
mechanical irritation by interdigital nerve compression under the transverse metatarsal ligament;4 however, in this case, it may be neural irritation from the bony bridge. To avoid this problem, we recommend that special attention be paid to avoid wire penetration into middle metatarsals, and meticulous surgical technique with appropriate soft tissue handling and dissection.
References 1. Hart DJ, Hart DJ. Iatrogenic metatarsal coalition: a postoperative complication of adjacent V-osteotomies. J. Foot Surg. 1985; 24: 205–8. 2. Atar D, Grant AD, Lehman WB. Intermetatarsal synostosis after treatment with Ilizarov apparutus: a case report. Bull. Hosp. Jt. Dis. 1992; 52: 12.
Images for surgeons
3. Faraj AA, Shaikh MR. Synostosis between first and second metatarsal joint following Mitchell’s osteotomy. Eur. J. Orthop. Traumatol. 2009; 19: 59–61. 4. Llanos LF, Vila J, Nunez-Samper M. Clinical symptoms and treatment of the foot and ankle nerve entrapment syndromes. Foot Ankle Surg. 1999; 5: 211.
Nicholas Russell,* BMBS, BE (Hons) Peter Stavrou,* MBBS, FRACS George Dracopoulos,† MBBS, FRACS *Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, and †Department of Orthopaedics, The Memorial Hospital, North Adelaide, South Australia, Australia doi: 10.1111/ans.12268
Incarcerated obturator hernia: a rare clinical entity A thin 82-year-old woman was admitted to our hospital by the general practitioner with abdominal pain. Her medical history revealed Parkinson’s disease since several years. She had no surgical history of the abdomen. She complained of increasing abdominal pain in the right lower abdomen with nausea, but without vomitus. She had defecation the same day. On physical examination, she had a distended abdomen with loud bowel sounds. Palpation revealed tenderness in the right lower abdomen without signs for peritonitis. She had no palpable hernias. On digital rectal exam, no palpable masses were found. Plain abdominal X-ray showed small bowel distension without any indications for the cause of this distention. Further analysis by computed tomography scan demonstrated an incarcerated obturator hernia (Fig. 1). The patient was admitted to the operating room where a subumbilical midline laparotomy was performed. During inspection of the abdominal cavity, the small bowel reduced spontaneously from the obturator foramen (Fig. 2). The small bowel was slightly indurated without any permanent damage. The hernial sac (Fig. 3) was mobilized and ligated, followed by a preperitoneal mesh repair. The post-operative episode was complicated by infection with clostridium difficile which was treated successfully with vancomycin. She could leave the hospital 12 days following surgery. No recurrence was observed up to 6 months after surgery. An obturator hernia is a protrusion of intraperitoneal or extraperitoneal tissue through the obturator canal where it follows the natural path of the obturator nerve, artery and vein. It is a rare variety among abdominal hernias and accounts for approximately 1% of all hernias. Mortality of obturator hernia ranges from 11% to 70%,1,2 probably due to its unfamiliarity and thereby its late recognition. Beause the frequency of obturator hernias is five to six times higher in emaciated women in their seventies or eighties it is also called ‘the skinny old lady hernia’.3 Indeed, women are affected six to nine times more often than men because of their wider pelvis, larger obturator canal and multiple pregnancies.4 Moreover, emaciation and malnourishment leading to a thin body habitus will lead to
Fig. 1. Computed tomography scan of the abdomen showing the protrusion of small bowel through the obturator canal, indicating an incarcerated obturator hernia (red arrow).
reduced preperitoneal fatty tissue that normally supports the obturator canal. Conditions resulting in increased intra-abdominal pressure such as constipation or chronic airway obstruction may increase the risk of developing an obturator hernia, especially in aforementioned patients.5 However, these conditions have never been subject of study. Patients with a (incarcerated) obturator hernia usually present with aspecific signs of bowel obstruction. Therefore, diagnosis is seldom made without additional imaging studies. Nevertheless, two typical signs can be observed in a subpopulation of patients. First, in © 2013 Royal Australasian College of Surgeons
Images for surgeons
Fig. 2. Intraoperative photograph showing the widened right obturator canal.
293
laparatomy, several approaches are suggested in literature.4,8 First, the transabdominal approach is most commonly used as in most cases an exact diagnosis is not made prior to surgery. It allows for good exposure of the obturator rings at both sides, so a bilateral obturator hernia might be diagnosed and treated. Moreover, it is recommended in cases where bowel necrosis is expected because intra-abdominal pathology can be corrected immediately. Second, extraperitoneal approaches can be performed in cases where a preoperative diagnosis has been made. The retropubic approach will reveal cavum Retzii, providing bilateral access to the obturator areas. The obturator approach is used in cases of a palpable mass in the obturator area. Direct incision over the palpable mass followed by division of the fascia lata and retracting the exposing adductor longus medially and the pectineus laterally may reveal the hernia sac.4,8 In cases of a small hernia, the hernia defect is closed by several interrupted sutures, with subsequent stabilization of the closure using muscle flaps, omentum or broad ligament of the uterus. Nowadays, prosthetic meshes are used to cover the defects in most cases.9 Early diagnosis and treatment of the obturator hernia are the most important factors in decreasing its morbidity and mortality. As a consequence, rapid action for diagnosis and operative therapy is essential.
References
Fig. 3. Intraoperative photograph showing the spontaneously reduced hernial sac, which was ligated.
approximately 50% of patients obturator neuralgia exists.6 Because of compression of the cutaneous branch of the obturator nerve by the incarcerated hernia, patients may experience pain, hyper- or hypoesthesia or cramps down the inner surface of the thigh to the knee. The symptoms are exacerbated by coughing, extension, adduction, and medial rotation of the thigh and relieved by flexion.7 Second, loss of the thigh adductor reflex in the presence of a positive patellar reflex is also due to the obturator nerve compression causing adductor muscles weakness and is known as the Hannington–Kiff sign. The latter is thought to be more specific for obturator hernia, but is less frequently present.6,7 Although manual reduction of an incarcerated obturator hernia is a short-term solution, surgical repair is needed because recurrence rates of approximately 10% are reported.4 If reduction is not possible an immediate intervention is mandatory, either by laparotomy or by laparoscopy. The latter is performed preferably in elective cases. In
© 2013 Royal Australasian College of Surgeons
1. Angstman KB, Myers JW, Olson RT. Obturator hernia – a rare cause of intestinal obstruction. J. Fam. Pract. 1986; 23: 370–2. 2. Yokoyama Y, Yamaguchi A, Isogai M, Hori A, Kaneoka Y. Thirty-six cases of obturator hernia: does computed tomography contribute to postoperative outcome? World J. Surg. 1999; 23: 214–6, discussion 217. 3. Naude G, Bongard F. Obturator hernia is an unsuspected diagnosis. Am. J. Surg. 1997; 174: 72–5. 4. Stamatiou D, Skandalakis LJ, Zoras O, Mirilas P. Obturator hernia revisited: surgical anatomy, embryology, diagnosis, and technique of repair. Am. Surg. 2011; 77: 1147–57. 5. Losanoff JE, Richman BW, Jones JW. Obturator hernia. J. Am. Coll. Surg. 2002; 194: 657–63. 6. Schmidt PH, Bull WJ, Jeffery KM, Martindale RG. Typical versus atypical presentation of obturator hernia. Am. Surg. 2001; 67: 191–5. 7. Mandarry MT, Zeng SB, Wei ZQ, Zhang C, Wang ZW. Obturator hernia – a condition seldom thought of and hence seldom sought. Int. J. Colorectal Dis. 2012; 27: 133–41. 8. Nishina M, Fujii C, Ogino R et al. Preoperative diagnosis of obturator hernia by computed tomography. Semin. Ultrasound CT MR 2002; 3: 193–6. 9. Uludag M, Yetkin G, Kebudi A, Isgor A, Akgun I, Dönmez AG. A rare cause of intestinal obstruction: incarcerated femoral hernia, strangulated obturator hernia. Hernia. 2006; 10: 288–91.
Maarten W. Nijkamp, MD, PhD Herman Frima, MD Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands doi: 10.1111/ans.12228
mechanical irritation by interdigital nerve compression under the transverse metatarsal ligament;4 however, in this case, it may be neural irritation from the bony bridge. To avoid this problem, we recommend that special attention be paid to avoid wire penetration into middle metatarsals, and meticulous surgical technique with appropriate soft tissue handling and dissection.
References 1. Hart DJ, Hart DJ. Iatrogenic metatarsal coalition: a postoperative complication of adjacent V-osteotomies. J. Foot Surg. 1985; 24: 205–8. 2. Atar D, Grant AD, Lehman WB. Intermetatarsal synostosis after treatment with Ilizarov apparutus: a case report. Bull. Hosp. Jt. Dis. 1992; 52: 12.
Images for surgeons
3. Faraj AA, Shaikh MR. Synostosis between first and second metatarsal joint following Mitchell’s osteotomy. Eur. J. Orthop. Traumatol. 2009; 19: 59–61. 4. Llanos LF, Vila J, Nunez-Samper M. Clinical symptoms and treatment of the foot and ankle nerve entrapment syndromes. Foot Ankle Surg. 1999; 5: 211.
Nicholas Russell,* BMBS, BE (Hons) Peter Stavrou,* MBBS, FRACS George Dracopoulos,† MBBS, FRACS *Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, and †Department of Orthopaedics, The Memorial Hospital, North Adelaide, South Australia, Australia doi: 10.1111/ans.12268
Incarcerated obturator hernia: a rare clinical entity A thin 82-year-old woman was admitted to our hospital by the general practitioner with abdominal pain. Her medical history revealed Parkinson’s disease since several years. She had no surgical history of the abdomen. She complained of increasing abdominal pain in the right lower abdomen with nausea, but without vomitus. She had defecation the same day. On physical examination, she had a distended abdomen with loud bowel sounds. Palpation revealed tenderness in the right lower abdomen without signs for peritonitis. She had no palpable hernias. On digital rectal exam, no palpable masses were found. Plain abdominal X-ray showed small bowel distension without any indications for the cause of this distention. Further analysis by computed tomography scan demonstrated an incarcerated obturator hernia (Fig. 1). The patient was admitted to the operating room where a subumbilical midline laparotomy was performed. During inspection of the abdominal cavity, the small bowel reduced spontaneously from the obturator foramen (Fig. 2). The small bowel was slightly indurated without any permanent damage. The hernial sac (Fig. 3) was mobilized and ligated, followed by a preperitoneal mesh repair. The post-operative episode was complicated by infection with clostridium difficile which was treated successfully with vancomycin. She could leave the hospital 12 days following surgery. No recurrence was observed up to 6 months after surgery. An obturator hernia is a protrusion of intraperitoneal or extraperitoneal tissue through the obturator canal where it follows the natural path of the obturator nerve, artery and vein. It is a rare variety among abdominal hernias and accounts for approximately 1% of all hernias. Mortality of obturator hernia ranges from 11% to 70%,1,2 probably due to its unfamiliarity and thereby its late recognition. Beause the frequency of obturator hernias is five to six times higher in emaciated women in their seventies or eighties it is also called ‘the skinny old lady hernia’.3 Indeed, women are affected six to nine times more often than men because of their wider pelvis, larger obturator canal and multiple pregnancies.4 Moreover, emaciation and malnourishment leading to a thin body habitus will lead to
Fig. 1. Computed tomography scan of the abdomen showing the protrusion of small bowel through the obturator canal, indicating an incarcerated obturator hernia (red arrow).
reduced preperitoneal fatty tissue that normally supports the obturator canal. Conditions resulting in increased intra-abdominal pressure such as constipation or chronic airway obstruction may increase the risk of developing an obturator hernia, especially in aforementioned patients.5 However, these conditions have never been subject of study. Patients with a (incarcerated) obturator hernia usually present with aspecific signs of bowel obstruction. Therefore, diagnosis is seldom made without additional imaging studies. Nevertheless, two typical signs can be observed in a subpopulation of patients. First, in © 2013 Royal Australasian College of Surgeons
Images for surgeons
Fig. 2. Intraoperative photograph showing the widened right obturator canal.
293
laparatomy, several approaches are suggested in literature.4,8 First, the transabdominal approach is most commonly used as in most cases an exact diagnosis is not made prior to surgery. It allows for good exposure of the obturator rings at both sides, so a bilateral obturator hernia might be diagnosed and treated. Moreover, it is recommended in cases where bowel necrosis is expected because intra-abdominal pathology can be corrected immediately. Second, extraperitoneal approaches can be performed in cases where a preoperative diagnosis has been made. The retropubic approach will reveal cavum Retzii, providing bilateral access to the obturator areas. The obturator approach is used in cases of a palpable mass in the obturator area. Direct incision over the palpable mass followed by division of the fascia lata and retracting the exposing adductor longus medially and the pectineus laterally may reveal the hernia sac.4,8 In cases of a small hernia, the hernia defect is closed by several interrupted sutures, with subsequent stabilization of the closure using muscle flaps, omentum or broad ligament of the uterus. Nowadays, prosthetic meshes are used to cover the defects in most cases.9 Early diagnosis and treatment of the obturator hernia are the most important factors in decreasing its morbidity and mortality. As a consequence, rapid action for diagnosis and operative therapy is essential.
References
Fig. 3. Intraoperative photograph showing the spontaneously reduced hernial sac, which was ligated.
approximately 50% of patients obturator neuralgia exists.6 Because of compression of the cutaneous branch of the obturator nerve by the incarcerated hernia, patients may experience pain, hyper- or hypoesthesia or cramps down the inner surface of the thigh to the knee. The symptoms are exacerbated by coughing, extension, adduction, and medial rotation of the thigh and relieved by flexion.7 Second, loss of the thigh adductor reflex in the presence of a positive patellar reflex is also due to the obturator nerve compression causing adductor muscles weakness and is known as the Hannington–Kiff sign. The latter is thought to be more specific for obturator hernia, but is less frequently present.6,7 Although manual reduction of an incarcerated obturator hernia is a short-term solution, surgical repair is needed because recurrence rates of approximately 10% are reported.4 If reduction is not possible an immediate intervention is mandatory, either by laparotomy or by laparoscopy. The latter is performed preferably in elective cases. In
© 2013 Royal Australasian College of Surgeons
1. Angstman KB, Myers JW, Olson RT. Obturator hernia – a rare cause of intestinal obstruction. J. Fam. Pract. 1986; 23: 370–2. 2. Yokoyama Y, Yamaguchi A, Isogai M, Hori A, Kaneoka Y. Thirty-six cases of obturator hernia: does computed tomography contribute to postoperative outcome? World J. Surg. 1999; 23: 214–6, discussion 217. 3. Naude G, Bongard F. Obturator hernia is an unsuspected diagnosis. Am. J. Surg. 1997; 174: 72–5. 4. Stamatiou D, Skandalakis LJ, Zoras O, Mirilas P. Obturator hernia revisited: surgical anatomy, embryology, diagnosis, and technique of repair. Am. Surg. 2011; 77: 1147–57. 5. Losanoff JE, Richman BW, Jones JW. Obturator hernia. J. Am. Coll. Surg. 2002; 194: 657–63. 6. Schmidt PH, Bull WJ, Jeffery KM, Martindale RG. Typical versus atypical presentation of obturator hernia. Am. Surg. 2001; 67: 191–5. 7. Mandarry MT, Zeng SB, Wei ZQ, Zhang C, Wang ZW. Obturator hernia – a condition seldom thought of and hence seldom sought. Int. J. Colorectal Dis. 2012; 27: 133–41. 8. Nishina M, Fujii C, Ogino R et al. Preoperative diagnosis of obturator hernia by computed tomography. Semin. Ultrasound CT MR 2002; 3: 193–6. 9. Uludag M, Yetkin G, Kebudi A, Isgor A, Akgun I, Dönmez AG. A rare cause of intestinal obstruction: incarcerated femoral hernia, strangulated obturator hernia. Hernia. 2006; 10: 288–91.
Maarten W. Nijkamp, MD, PhD Herman Frima, MD Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands doi: 10.1111/ans.12228
