|Year : 2021 | Volume
| Issue : 2 | Page : 79-82
A new technique for the incarcerated ileum reduction during laparoscopic obturator hernia repair: A case report and systemic review
Yunliang Zhang, Xiaojun Xie, Shubiao Chen, Dewang Chen
Department of Hernia and Abdominal Wall Surgery, The 1st Affiliated Hospital of Shantou University Medical College, Shantou City, Guangdong Province, China
|Date of Submission||16-Nov-2020|
|Date of Decision||21-Nov-2020|
|Date of Acceptance||27-Nov-2020|
|Date of Web Publication||31-May-2021|
Dr. Xiaojun Xie
No.57 Changping Road, Shantou City, Guangdong Province
Source of Support: None, Conflict of Interest: None
Obturator hernia (OH) is a rare condition in all abdominal wall hernias, which usually presents with the symptoms of bowel obstruction caused by incarcerated intestinal segment, generally the ileum. We report a clinical case of an 81-year-old thin woman with 8-day history of nausea, vomiting, abdominal pain, and distension that aggravated for 1 day. A computed tomography scan showed an intestinal segment herniated into the obturator foramen in the left pelvic floor. A diagnosis of a left ileal, strangulated OH was made. A protective reduction management, air replacement method, was used to reduce the incarcerated ileum. Nonspecific symptoms of OH add difficulty in making diagnosis. Symptoms of bowel obstruction in patients with OH indicate incarceration. It is commonly seen in thin, elderly, multiparous women. Several ways for the reduction in patients with strangulated OH are described. Surgical approaches are the only choice for treatment. OH, a rare type in all hernias, is difficult to be diagnosed because of nonspecific symptoms. Air replacement method can reduce the incarcerated ileum successfully without unintentional injury.
Keywords: Air replacement method, bowel obstruction, laparoscopic repair, obturator hernia
|How to cite this article:|
Zhang Y, Xie X, Chen S, Chen D. A new technique for the incarcerated ileum reduction during laparoscopic obturator hernia repair: A case report and systemic review. Int J Abdom Wall Hernia Surg 2021;4:79-82
|How to cite this URL:|
Zhang Y, Xie X, Chen S, Chen D. A new technique for the incarcerated ileum reduction during laparoscopic obturator hernia repair: A case report and systemic review. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Sep 19];4:79-82. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/2/79/317319
| Introduction|| |
Obturator hernia (OH) is a relatively rare type of all abdominal wall hernias. It is also an uncommon but important cause of bowel obstruction, especially in thin, elderly, multiparous women., Signs and symptoms resulting from OH are nonspecific. Patients with a bowel obstruction caused by strangulated OH present with nausea and vomiting, abdominal pain, abdominal distension, and a lack of bowel movement. Computed tomography (CT) scan enhances preoperative diagnostic accuracy and surgical treatment is the only choice. Early diagnosis and treatment of OH can help to decrease morbidity and mortality rates.
I present this interesting case of an elderly thin woman with small intestine obstruction caused by strangulated OH and describe a new technique for the incarcerated ileum reduction during laparoscopic OH repair.
| Presentation of Case|| |
An 81-year-old thin woman (body mass index: 17.8) was admitted to the hospital on September 22, 2019, with 8-day history of nausea, vomiting, abdominal pain, and distension that aggravated for 1 day. Physical examination showed soft but distended abdomen, tenderness at the left iliac fossa. No masses could be found clinically. Abdominal CT [Figure 1] and [Figure 2] scan showed an intestinal segment herniated into the obturator foramen in the left pelvic floor. The corresponding small intestine wall was slightly thickened and the above small intestinal tract had dilatation and effusion with gas-liquid plane inside. A suspicion of OH causing small intestine obstruction was raised.
|Figure 1: Pelvic computed tomography scan images show the small intestine herniating into the left obturator canal anterior to the obturator externus muscle|
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|Figure 2: Coronal and Saggital Pelvic computed tomography scan images show the small intestine herniating into the left obturator canal|
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Emergency laparoscopic exploration was performed on September 23, 2019. A moderate amount of lightyellow exudate was seen in the pelvis, and the flatulence of the intestine was obvious. An obturator foramen with a size of about 2 cm × 2 cm was seen on the left side. The contents of the hernia were part of the small intestine [Figure 3]. No obvious abnormality was found in the remaining abdominal cavity. A diagnosis of the left strangulated OH with bowel obstruction was confirmed.
|Figure 3: Laparoscopic exploration image shows the incarcerated ileum in the left obturator canal|
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Under general anesthesia, utilizing nontraumatic forceps or intestinal holding forceps to pull the intestinal tract out of the obturator foramen failed. Because of the edema and brittleness of the incarcerated contents, rough traction may lead to the rupture of the intestine, causing bleeding and intraabdominal infection. A new technique [Figure 4] for the incarcerated ileum reduction (Air Replacement Method) was performed successfully. A 12Fr silica gel catheter was placed into the trocar hole on the left side. With the help of the nontraumatic forceps, the catheter end was placed into the hernia sac along the intestinal wall. The pneumoperitoneum pressure was lowered to 6–8 mmHg. The assistant used a 50 ml syringe to inject air into the hernia sac through the other end of the catheter rapidly so that the internal pressure of the hernia sac increased to be greater than the internal pressure of the abdominal cavity. As more and more air entered the hernia sac, the incarcerated content with bloody fluid came out gradually. Finally, the herniated content was replaced by air and the incarcerated ileum was reduced completely.
|Figure 4: (a) Using a 50 ml syringe to inject air into the hernia sac through the outside end of the catheter. (b) The inside end of the catheter after reducing the incarcerated ileum successfully|
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The length of the incarcerated ileum wall was about 3 cm. Forty minutes after reduction, the blood supply and peristalsis of the ileum were normal. No obvious perforation or necrosis could be found [Figure 5]. Laparoscopic transabdominal preperitoneal (TAPP) OH repair was performed. The defect was filled with two pieces of cotton sponge and repaired with a 15 cm × 9 cm Medtronic self-fixing mesh. Using 3–0 Vicryl sutured the parietal peritoneum. The patient had a satisfactory postoperative course and was discharged on the 3rd postoperative day. One month later, CT scan confirmed the fixation of the mesh in the left obturator foramen and no hernias.
|Figure 5: Laparoscopic image shows no perforation or necrosis of the ileum after reduction|
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| Discussion|| |
OH is a rare clinical condition that can cause bowel obstruction, which accounts for only 0.5%–1.4% in all abdominal wall hernias. Pierre Roland Arnaud de Ronsil reported the first case of OH in 1724 and Henry Ombre conducted the first operation successfully in 1851. It is more common in women than in men, which may be due to the wider and more oblique pelvis and the greater transverse diameter of the obturator foramen in female. The predisposing factors include elderly age, pregnancy, constipation, multiparity, chronic obstructive pulmonary disease, ascites, and defective collagen metabolism.
Clear understanding of the anatomy of the obturator region is important to make the correct diagnosis and perform a successful operation. Obturator foramen is the hole created by the ischium and pubis bones of the pelvis, which is closed by obturator membranes and muscles. The obturator canal is a passageway formed in the obturator foramen by part of the obturator membrane. It connects the pelvis to the thigh. The obturator artery, obturator vein, and obturator nerve all travel through the canal obliquely downward and upward.
Three stages are described in the formation of OH. Stage 1, preperitoneal fatty tissue enters the obturator canal. Stage 2, a true hernia sac is formed. Stage 3, the viscera, generally the ileum, herniates into the sac, and generating the symptoms of bowel obstruction. Most of the patients with OH present with the symptoms of bowel obstruction, such as nausea and vomiting, abdominal pain, abdominal distension, a lack of bowel movement, and so on. Due to the nonspecific symptoms, it is difficult to make early diagnosis. The accurate diagnosis of OH usually can be made during operations for bowel obstruction. CT scan serves as an essential tool for diagnosing OH with a high preoperative accuracy, which can decrease both morbidity and mortality rates.
There are several ways for the reduction in patients with strangulated OH. Preoperative reduction can be reached by compressing the caudal border of the herniated segment under the guidance of ultrasound. During traditional laparotomy, surgeon pulls the incarcerated intestine gently for reduction. Under the general anesthesia, using the nontraumatic forceps can pull out the incarcerated contents gently for reduction. However, in my case, gentle pulling for reduction failed. To prevent tearing of the ileum, a new technique for reduction (Air replacement method) was performed. Placing a 12Fr silica gel catheter into the hernial sac and injecting air inside. Lowering the pressure of the pneumoperitoneum at the same time. As the pressure inside the hernial sac increases, the herniated contents come out gradually until complete reduction. Successful reduction can help to decrease intestinal resection rate.
Surgical treatment of OH is the only choice. Several different operative approaches have been described, including retropubic, inguinal, abdominal, obturator, and laparoscopic approaches. Most of the surgeons prefer the abdominal approach with a low midline incision because it can help to confirm the diagnosis and provider better exposure of the obturator foramen. Furthermore, the surgeons can resect the necrotic intestine directly. However, the laparoscopic approach becomes more and more popular because of its advantages, such as less postoperative pain, short hospital stays, less cardiovascular, and pulmonary complications. In my case, laparoscopic TAPP repair of OH was performed successfully. The recovery course was satisfactory.
| Conclusion|| |
OH with incarcerated ileum is a relatively rare clinical emergency condition. Although most of the patients present with the symptoms of bowel obstruction, CT scan still serves as an essential tool for accurate diagnosis preoperatively, which can help to decrease both morbidity and mortality rates. Air replacement method, a protective reduction management, is really helpful and important in patients with incarcerated contents that are difficult to be reduced, which can help to decrease the intestinal resection rate. Laparoscopic TAPP repair of OH with a Medtronic self-fixing mesh reaches a highly satisfactory result in elderly thin female patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Conti L, Baldini E, Capelli P, Capelli C. Bowel obstruction in obturator hernia: A challenging diagnosis. Int J Surg Case Rep 2018;42:154-7.
Cheng-Chieh Y. Small intestine obstruction secondary to obturator hernia. Adv Dig Med 2017;4:148-9.
Ayoub K, Mahli N, Dabbagh MF, Banjah B, Banjah B. Left sided Richter type obturator hernia causing intestinal obstruction: A case report. Ann Med Surg (Lond) 2018;36:1-4.
Nakayama T, Kobayashi S, Shiraishi K, Nishiumi T, Mori S, Isobe K, et al
. Diagnosis and treatment of obturator hernia. Keio J Med 2002;51:129-32.
Kammori M, Mafune K, Hirashima T, Kawahara M, Hashimoto M, Ogawa T, et al
. Forty-three cases of obturator hernia. Am J Surg 2004;187:549-52.
Pavlidis E, Kosmidis C, Sapalidis K, Tsakalidis A, Giannakidis D, Rafailidis V, et al
. Small bowel obstruction as a result of an obturator hernia: A rare cause and a challenging diagnosis. J Surg Case Rep 2018;2018:rjy161.
Julian EL, Bruce WR, James WJ. Obturator hernia. J Am Coll Surg 2002;194:657-63.
Petrie A, Tubbs RS, Matusz P, Shaffer K, Loukas M. Obturator hernia: Anatomy, embryology, diagnosis, and treatment. Clin Anat 2011;24:562-9.
Shipkov CD, Uchikov AP, Grigoriadis E. The obturator hernia: Difficult to diagnose, easy to repair. Hernia 2004;8:155-7.
Light D, Razi K, Horgan L. Computed tomography in the investigation and management of obturator hernia. Scott Med J 2016;61:103-5.
De Kok BM, Puylaert JB, Zijta FM. Ultrasound-guided reduction of an incarcerated obturator hernia in an elderly patient. J Clin Ultrasound 2017;46:6.
Otsuki Y, Konn H, Takeda K, Koike M. Midline extraperitoneal approach for obturator hernia repair. Keio J Med 2018;67:67-71.
Hayama S, Ohtaka K, Takahashi Y, Ichimura T, Senmaru N, Hirano S. Laparoscopic reduction and repair for incarcerated obturator hernia: Comparison with open surgery. Hernia 2015;19:809-14.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]