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| REVIEW ARTICLES |
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| Year : 2021 | Volume
: 4
| Issue : 4 | Page : 166-173 |
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A case report and a contemporary review of incarcerated and strangulated obturator hernia repair
Sergio Mazzola Poli de Figueiredo, Luciano Tastaldi, Rui-Min Diana Mao, Richard Lu, Douglas Tyler, Alexander Perez
Department of Surgery, University of Texas Medical Branch Hospital, Galveston, Texas, USA
| Date of Submission | 07-Sep-2021 |
| Date of Acceptance | 22-Sep-2021 |
| Date of Web Publication | 31-Dec-2021 |
Correspondence Address:
Dr. Sergio Mazzola Poli de Figueiredo
Department of Surgery, University of Texas Medical Branch Hospital, 301 University Blvd, Galveston, Texas 77555.
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_60_21
BACKGROUND: Obturator hernia (OH) usually presents as a surgical emergency, with open primary repair most commonly performed. Given the morbidity and high recurrence of this approach, we present a case and review the literature to evaluate the influence of the operative approach on OH repair. METHODS: A literature search via PubMed was performed. Inclusion criteria were studies that: (1) were written in English and published within 10 years; (2) included as keywords “obturator hernia” and/or “incarcerated” and/or “strangulated”; (3) reported the operative approach; and (4) reported postoperative outcomes. RESULTS: Overall, 225 studies were identified, and 53 met the inclusion criteria. Data from 425 patients were pooled. Open repair without mesh was performed in 239 (56.2%) patients, 121 (28.5%) had open repair with mesh, 44 (10.4%) had laparoscopic repair with mesh, and 21 (4.9%) had laparoscopic repair without mesh. Open repair had a mean hospital length of stay (LOS) of 13.4 days, 40.3% postoperative complications, and 9.7% 30-day mortality rate whereas laparoscopic repair had a mean LOS of 7.9 days, 3.1% postoperative complications, and no deaths. Small bowel resection (SBR) was performed in 44.7% of open and 15.4% of laparoscopic repairs. Patients with SBR demonstrated higher morbidity and mortality compared with patients without SBR. In patients without SBR, laparoscopy had advantages over open surgery in LOS, complications, and mortality rate. The overall recurrence rate was 7.7%, with a mean follow-up of 20.4 months. One (0.7%) recurrence was reported in mesh repair, whereas 28 (12.1%) recurrences were reported with tissue repair. CONCLUSION: OHs are the most common open repair without mesh. Our literature review showed that laparoscopic OH repair is associated with enhanced postoperative recovery and the use of mesh was associated with less recurrence. Further studies are still necessary to determine the optimal approach for OH repair, but laparoscopic repair with mesh should be performed when possible. Keywords: Laparoscopic hernia repair, literature review, mesh repair, obturator hernia
How to cite this article:
Mazzola Poli de Figueiredo S, Tastaldi L, Mao RMD, Lu R, Tyler D, Perez A. A case report and a contemporary review of incarcerated and strangulated obturator hernia repair. Int J Abdom Wall Hernia Surg 2021;4:166-73 |
How to cite this URL:
Mazzola Poli de Figueiredo S, Tastaldi L, Mao RMD, Lu R, Tyler D, Perez A. A case report and a contemporary review of incarcerated and strangulated obturator hernia repair. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Jun 29];4:166-73. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/166/334564 |
| Introduction | |  |
Obturator hernias (OHs) are rare and usually seen in frail elderly female patients with multiple comorbidities.[1],[2] The symptoms are often related to an acute small bowel obstruction. Mortality has been reported to reach up to 47.6%,[3],[4],[5],[6],[7],[8] warranting prompt surgical intervention.
Numerous techniques have been described to repair OH,[1] traditionally being an exploratory laparotomy with primary hernia repair and bowel resection, if indicated. With the advancements in minimally invasive surgery, several authors reported that laparoscopic repair of incarcerated OH is feasible and has lower incidence of postoperative complications.[4],[5],[6],[9],[10],[11],[12]
Laparoscopic transabdominal preperitoneal hernioplasty (TAPP) is favored in the setting of acute incarceration,[13] as it permits inspection of the abdominal cavity, assessment of bowel viability and allows for wide mesh coverage of the myopectineal orifice, thus decreasing recurrence rates.[7],[12] Although ideal, sometimes laparoscopic TAPP may not be possible. An open primary repair is also appropriate in the setting of significant small bowel distention, strangulation, patient’s inability to tolerate the pneumoperitoneum, and the surgeon’s lack of experience with laparoscopy.
Given its rarity, literature regarding OH is limited to small case series and case reports, with most of them lacking long-term follow-up. We aim at reporting the use of a laparoscopic TAPP approach for the repair of bilateral recurrent OHs after an early recurrence from an open transabdominal repair. In addition, we sought to review the literature focusing on outcomes comparison between different techniques in OH repair.
| Materials and Methods | | |
A literature search was conducted using the keyword “obturator hernia” in the PubMed database on July 10, 2020. Inclusion criteria were studies that: (1) were written in the English language and were published within the past 10 years; (2) included as keywords the terms “obturator hernia” and/or “incarcerated” and/or “strangulated”; (3) reported the operative approach used for repair; and (4) reported postoperative outcomes.
The outcomes of interest included surgical approach, use of mesh, length of hospital stay, overall complications, mortality, and long-term hernia recurrence.
Informed patient consent was obtained for publication of the case details, and all identifying information was removed to protect patient privacy. The local institutional review board approved the study.
| Case Presentation | | |
An 84-year-old woman with a body mass index (BMI) of 14 kg/m2 presented to the emergency department with a one-week history of intermittent right groin pain that had worsened within the past 24 h accompanied by nausea, absence of flatus, and bowel movement for two days. Her medical history included hypertension and chronic obstructive pulmonary disease. Four months earlier, the patient had similar symptoms and was found to have a small bowel obstruction from an acutely incarcerated right OH [Figure 1] and [Figure 2]. At that time, the patient underwent an open primary repair via a midline incision. A contralateral OH was noted and repaired. The patient had an uneventful postoperative course and was discharged on postoperative Day 7. | Figure 1: Preoperative CT (axial view) showing small bowel obstruction with right-sided OH at first presentation (red arrow)
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 | Figure 2: Preoperative CT (coronal view) showing small bowel obstruction with right-sided OH at first presentation (red arrow)
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She was readmitted to the hospital for observation on postoperative Day 19 due to abdominal pain secondary to constipation, as imaging did not show any signs of recurrence or postoperative complications [Figure 3]. On physical examination, the patient had abdominal distension and right lower quadrant tenderness. There were no palpable abdominal or inguinal masses. A leukocytosis of 15,000 was noted. A computed tomography (CT) abdomen and pelvis was obtained, which demonstrated dilated loops of small bowel with a recurrent right OH [Figure 4]. Given the earlier findings, the decision was made to proceed with emergent diagnostic laparoscopy. | Figure 3: CT performed during readmission from index operation on postoperative day 19 without any signs of recurrence
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 | Figure 4: Preoperative CT showing small bowel obstruction with right-sided recurrent OH four months after index operation (red arrow)
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On entry to the abdomen, an incarceration of the antimesenteric border of a loop of small bowel (Richter-type hernia) was noted on the right obturator foramen. The bowel was reduced and noted to be viable. A recurrent left OH was identified. A laparoscopic TAPP bilateral recurrent OH repair was then performed with permanent synthetic mesh [Figure 5] and [Figure 6]. Her postoperative course was uneventful, and the patient was discharged home 9 h after the operation. On her two-week [Figure 7] and six months’ postoperative follow-up, the patient was asymptomatic. A comparison between the two admissions requiring surgical intervention can be seen in [Table 1].  | Table 1: Comparison of the two operative interventions performed in our patient
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| Results | | |
A total of 225 studies were found using our keywords in the PubMed database, and 53 studies met the inclusion criteria for our analysis. The total number of patients pooled from all studies is 425. The mean age of the patients was 83.3 years old; 419 (98.6%) were females and six (1.4%) were males. The mean BMI was 18.1 kg/m2.
Fifty articles reported laterality of the OH, including 289 patients. Among those patients, 60 (20.8%) were found to have bilateral OH. For discrimination of left- and right-side OH prevalence, we excluded three studies that did not mention any laterality other than the presence of bilateral hernias, including a total of 200 patients. In these patients, there were 137 (51.7%) left-sided OHs and 128 (48.3%) right-sided OHs. Forty-seven patients (23.5%) had bilateral OHs. Thirty-five articles mentioned laterality based on preoperative workup and laterality found intraoperatively, including 98 patients. The incidence of occult contralateral hernia found intraoperatively was 12.2% (12 patients).
In patients who underwent open surgery, 239 (56.2%) had primary repair whereas 121 (28.5%) had mesh repair. In the group who had laparoscopic repair, 44 (10.4%) underwent mesh repair and 21 (4.9%) underwent primary repair. Overall, SBR was performed in 171 (40%) patients: 161 patients in the open group and 10 in the laparoscopic group.
Perioperative outcomes
An open approach was performed in 360 patients, and 161 (44.7%) of these patients underwent SBR. The mean hospital LOS was 13.4 days, and the rate of postoperative complications was 40.3% [Table 2]. Postoperative complications included: prolonged ileus, pneumonia, congestive heart failure exacerbation, respiratory failure, arrhythmias, Clostridium difficile infection, surgical site infection, and surgical site hematoma. The 30-day mortality rate in patients who underwent open repair was 9.7%. A laparoscopic approach was performed in 65 patients, and 10 (15.4%) underwent SBR. The mean LOS in the laparoscopic group was 7.9 days, and the rate of postoperative complications was 3.1%. No patients who underwent laparoscopic repair died within 30 days of operation. | Table 2: Comparison of postoperative outcomes in open and laparoscopic approach
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Differences in patients who underwent small bowel resection/repair and no small bowel resection/repair
A total of 181 patients were selected for an analysis of the difference in the outcomes of patients who underwent SBR/repair (55 patients) or not (126 patients). The laparoscopic approach was used in 43.6% of patients in the non-SBR group and in 14% of patients in the SBR group [Table 3]. The mean LOS was 9.5 days in patients who did not undergo bowel resection/repair and it was 17.7 days in patients who underwent bowel resection/repair. The complication rate was 16% and 30-day mortality rate was 3.2% in the non-SBR group, whereas they were 50.9% and 10.9%, respectively, in the SBR group. | Table 3: Postoperative outcomes on patient with bowel resection and without bowel resection
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Open versus laparoscopic approach in patients who did not undergo small bowel resection
A total of 126 patients who did not undergo SBR were selected. An open approach was performed in 71 patients (56.3%). These patients had a mean LOS of 12 days, a postoperative complication rate of 25.3%, and a 30-day mortality rate of 5.6% [Table 4]. A laparoscopic approach was used in 55 patients (45.7%). These patients had a mean LOS of 6.5 days, a postoperative complication rate of 3.6% and no deaths occurred within 30 days of surgery. | Table 4: Postoperative outcomes on patient who did not undergo bowel resection
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Long-term outcomes and recurrence
The pooled recurrence rate of laparoscopic and open repairs was 7.7%, with a mean follow-up of 20.5 months. The overall recurrence rate in the open group was 7.9%; open repair with mesh demonstrated a recurrence rate of 0.9% and open repair without mesh exhibited a recurrence rate of 11.4% at a mean follow-up of 21.3 months. The overall recurrence rate in the laparoscopic repair group was 6.1% with a mean follow-up of 37.5 months; all of them were from laparoscopic primary repair, which had a 25% recurrence rate. No recurrences were reported with laparoscopic mesh repairs. Regardless of the surgical approach, only one recurrence was reported in mesh repair (0.7%), whereas 28 (12.1%) were reported with non-mesh repair [Table 5]. Eleven studies (20.7%) reported a follow-up period greater than 24 months, with a total of 232 patients (54.5%). Of these patients with reported long-term outcomes, the long-term mortality was found to be 40.9% with a mean follow-up of four years (48.6 months). Studies that had a mean follow-up of more than two years reported 79.3% of all recurrences noted overall (23 out of 29). | Table 5: Recurrence rates on mesh and non-mesh repair group (mean follow-up of 20.5 months)
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| Discussion | | |
OHs are rare and account for only 0.07%–1% of all abdominal wall hernias and 0.2%–1.6% of all small bowel obstructions.[1] With the steady increase in the elderly population, the advent of imaging such as computed abdominal tomography, and the increase in laparoscopic abdominal wall hernia repair, the number of patients diagnosed with OH is increasing.[3],[7],[14] As observed in our review of the literature, this condition is predominant in females (98.6% of patients) due to a wider pelvis and greater diameter of the obturator canal.[2] Low BMI is also associated with herniation in the area due to a loss of preperitoneal fat within the obturator foramen. Comorbidities such as chronic obstructive pulmonary disease, constipation, and kyphoscoliosis are additional risk factors for herniation.[2] Our patient demonstrated many of these characteristics.
The clinical presentation is usually nonspecific, with the classic finding of medial thigh pain caused by compression of the obturator nerve (Howship Romberg sign) being present in less than 50% of the cases.[8] Thus, imaging modalities are important tools in the diagnosis of OHs, with CT imaging reported to have 90% sensitivity.[5],[8] We observed a significant prevalence of bilateral OHs (20.8%), which is higher than previously reported.[2] This finding is likely secondary to better detection with imaging and an increase in laparoscopic OH repair. Even with the liberal use of CT for preoperative workup and its high sensitivity, we found that 12.2% of patients had an occult contralateral OH. Bilateral disease can be an important consideration regarding the choice of operative technique, as postoperative incarceration in the contralateral side of the repair has been described.[15],[16]
Given the elderly and frail characteristic of this patient population as well as the tendency to present with small bowel obstruction, mortality rate is estimated to range from 10% to 47.6%.[3],[6],[7],[8],[14],[17] A few studies reported long-term survival, but it has been described to be 74% at two years and 55% in five years.[7] Early operative intervention is associated with a decreased need for bowel resection and overall mortality.[1],[3],[18],[19] Our patient was taken urgently to the operating room within 8 h of presentation in both hospital admissions and did not have signs of bowel necrosis at either time of operative intervention.
Since most patients present with acute small bowel obstruction, exploratory laparotomy is commonly performed. However, many other options exist, including open extra-abdominal approaches (preperitoneal, obturator, and inguinal) and laparoscopic approaches (TAPP and TEP).[1] Laparoscopic repair was previously thought to be restricted to elective repairs, but recently many studies have demonstrated that laparoscopic repair is feasible in the setting of incarceration, has a lower hospital LOS and incidence of postoperative complications.[4],[5],[6],[9],[10],[11],[12] Our patient had significant differences in hospital LOS when comparing both hospital admissions (0.6 days vs. 7 days), which is more likely attributed to the difference in surgical approach. Our review of the literature also highlights the advantages of the laparoscopic approach on postoperative recovery in patients with OHs. Laparoscopic repair had almost half of the hospital LOS of open repair, more than a 10-fold decrease in postoperative complications, and no deaths within 30 days of repair whereas open repair had 9.7% 30-day mortality. It is important to highlight that more patients in the open repair group underwent SBR, which was associated with worse postoperative outcomes, as shown in [Table 3]. Laparoscopic repair demonstrated improved postoperative outcomes regardless of bowel resection [Table 4]. It is evident that laparoscopic approaches are advantageous in comparison to open surgery.
There are no studies comparing TAPP and TEP for OH repair; but given that TAPP allows you to perform a full inspection of the abdominal cavity, assessment of bowel viability, and improved ability to manipulate incarcerated viscera, we suggest that TAPP should be the preferred technique in the setting of incarceration. Studies comparing TAPP and TEP were performed in inguinal and femoral hernia repairs, and TAPP was reported to be the preferred approach in the setting of incarceration.[13]
Multiple techniques for OH repair have been described, including primary repair, use of tissue flaps, coverage with adjacent structures, and use of prosthetic materials. Similar to the repair of other abdominal wall hernias, mesh placement is associated with less recurrence than tissue repair in OHs.[12] In our study, overall recurrence was similar in the open and laparoscopic repair group but the use of mesh resulted in significantly less recurrences in both groups, suggesting that recurrences are more affected by mesh placement rather than the surgical approach. Given that our patient did not have a strangulated bowel at the first operative intervention, use of mesh could have prevented a recurrence of the index operation and prevented a second emergent operation.
Based on our review of the literature, only 54.5% of the patients described in the literature with OH have a follow-up of more than two years. This is concerning for the underreporting of OH recurrence given that the mean follow-up period until recurrence is 23 months.[7] Follow-up more than two years reported almost 80% of the recurrences described in the literature. Even with the underestimated prevalence of OH recurrence, we found clinically significant less recurrence in mesh repairs (0.7%) than non-mesh repairs (12.1%). Given these findings, mesh should be used in OH repair unless contraindicated.
The setting of a strangulated OH with compromised small bowel is challenging and has been associated with an increase in mortality and postoperative complications.[14] Exploratory laparotomy is even more common in this scenario, but recently studies have shown that laparoscopy can also be performed. These minimally invasive approaches include a two-staged repair or hybrid procedure utilizing both minimally invasive and open techniques.[9],[12],[20]
The literature is limited on operative intervention for recurrent OHs given the rarity of the disease.[21],[22],[23] Laparoscopic TAPP repair is even more infrequent.[21] To our knowledge, this is the first report of laparoscopic TAPP repair after an early recurrence (four months) from an open transabdominal approach. We believe that laparoscopic TAPP is feasible in this setting and allows patients a significantly better perioperative outcome.
There are several limitations in our review of the literature analysis. Due to its rarity, the literature available on patients with OH is restricted to case reports and retrospective studies with significant heterogenicity. Despite focusing on incarcerated/strangulated OH repair, we included six patients who underwent elective repair and who were a part of two studies. We believe that these six patients do not affect our results greatly and the exclusion of these two studies would significantly impact the results of the study due to a decrease in the study population size. Despite the limitations mentioned earlier, we believe that our study is relevant in the setting of a rare disease and its results can more likely have an impact on the postoperative outcomes of these patients.
| Conclusion | | |
Although contemporary data suggest that laparoscopic OH repair is associated with enhanced postoperative recovery and that the use of mesh is associated with less recurrence than non-mesh repairs, OHs are still most commonly repaired open without mesh. Laparoscopic TAPP is a valuable option in the repair of incarcerated OH, even in the setting of an early recurrence from a previous open transabdominal approach as our case presentation demonstrates. Further studies are needed to determine the optimal approach for OH repair in the setting of incarceration and strangulation, but a laparoscopic mesh-based repair should be performed when patient and local conditions allow.
Financial support and sponsorship
Nil.
Conflicts of interest
Drs. Sergio Mazzola Poli de Figueiredo, Richard Lu, Douglas Tyler, and Alexander Perez have no conflicts of interest or financial ties to disclose.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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