Obturator Hernia

Ronald C. Speirs, MD
The Operative Review of Surgery. 2023; 1:314-317.

Download PDF

Table of Contents

Pathophysiology and Presentation
Diagnosis and Treatment

References

Pathophysiology and Presentation

Definition

  • Hernia Through the Obturator Foramen
  • Obturator Foramen Anatomy:
    • Located on the Anterolateral Aspect of the Pelvic Wall
    • Mostly Covered by a Fibro-Osseous Membrane
    • Open at the Anterosuperior Aspect – The Obturator Nerve, Artery, and Vein Enter the Obturator Canal
  • Very Rare (< 1% of Abdominal Wall Hernias)
  • High Morbidity and Mortality (15-25%) 1
    • Due to Delayed Diagnosis and Bowel Infarction
  • Most Often a Richter Hernia: Only the Antimesenteric Border of the Bowel Wall is Herniated 2
    • May Not Cause Obstruction as Bowel Contents Can Pass Through the Intraperitoneal Portion of the Bowel
    • High Risk of Incarceration and Strangulation of the Herniated Portion

Risk Factors 3-7

  • Loss of Preperitoneal Fat in the Obturator Canal Due to Cachexia or Profound Weight Loss
  • 9x More Common in Women (Wider Pelvis with Larger Obturator Canal)
  • Elderly (70-90 Years Old)
  • Multiparous
  • 2x More Common on the Right – Left Covered by the Sigmoid Colon
  • *Nicknamed “Little Old Lady’s Hernia”

Other Groin Hernias

Presentation

  • Clinical Presentation is Generally Nonspecific and Preoperative Diagnosis Can Be Difficult
  • Rarely See Proximal Thigh Mass Between the Pectineus and Adductor Longus Muscles – May Be Confused with a Femoral Hernia
  • Obturator Neuralgia – Ipsilateral Groin Pain Radiating to the Medial Knee
    • Due to Compression of the Obturator Nerve
  • Recurrent Episodes of Bowel Obstruction
    • Cramping Abdominal Pain
    • Nausea and Vomiting
    • Constipation
  • Risk for Bowel Incarceration, Strangulation, and Necrosis

Obturator Foramen 10

Richter Hernia 11

Diagnosis and Treatment

Signs of Obturator Neuralgia/Hernia

  • Howship-Romberg Sign 12
    • Ipsilateral Medial Groin/Thigh Pain Aggravated by Extension, Abduction, and Internal Rotation
  • Hannington-Kiff Sign 13
    • Absent Adductor Reflex with Positive Patellar Reflex
    • Adductor Reflex: Tapping of the Medial Epicondyle of the Femur Incites Hip Adduction
    • Patellar Reflex: Tapping of the Patellar Tendon Incites Knee Extension

Diagnosis

  • Imaging (CT, US, or MRI) Generally Used to Confirm Preoperative Diagnosis
  • May Be Diagnosed Intraoperatively During Exploration of a Bowel Obstruction 14

Treatment

  • All Should Undergo Early Surgical Repair Regardless of Symptoms
  • Higher Risk of Incarceration and Strangulation Preclude Watchful Waiting

Surgical Approach

  • Minimally Invasive (Laparoscopic/Robotic) Hernia Repair
  • Open Midline Laparotomy
    • Generally Preferred in Cases of Bowel Ischemia/Necrosis
  • Other Options:
    • Open Inguinal Approach
    • Open Obturator Approach
  • Bowel Reduction May Require Incision of the Obturator Membrane – Done at the Inferior Margin and Extended Inferomedial to Avoid Injury of the Nerve/Vessels 15

Right Obturator Hernia Seen on CT 16

Left Obturator Hernia (Circle) with Incidental Femoral Hernia at 11 O’clock Position 17

References

  1. Mindaye ET, Giduma D, Tufa TH. Obturator hernia: case report. J Surg Case Rep. 2020 Oct 19;2020(10):rjaa389.
  2. Treves F. Richter’s Hernia or Partial Enterocele. Med Chir Trans. 1887;70:149-67.
  3. 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 Feb;27(2):133-41.
  4. Kammori M, Mafune K, Hirashima T, Kawahara M, Hashimoto M, Ogawa T, et al.  Forty-three cases of obturator hernia. Am J Surg2004;187:549–52.
  5. Mantoo S, Mak K, Tan T. Obturator hernia: diagnosis and treatment in the modern era. Singap Med J2009;50:866–70.
  6. Kulkarni SR, Punamiya AR, Naniwadekar RG, Janugade HB, Chotai TD, Singh TV, et al.  Obturator hernia: a diagnostic challenge. Int J Surg Case Rep2013;4:606–8.
  7. Goon HK, Bahari HM. Obturator hernia: a case report. Med J Malaysia1983;38:200–2.
  8. Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am. 1993 Jun;73(3):413-26.
  9. Lockhart K, Dunn D, Teo S, Ng JY, Dhillon M, Teo E, van Driel ML. Mesh versus non-mesh for inguinal and femoral hernia repair. Cochrane Database Syst Rev. 2018 Sep 13;9(9):CD011517.
  10. Gray H. Anatomy of the Human Body (1918). Public Domain.
  11. Abo-elmagd A, Ahmed K. Richter Paraumbilical Hernia Managed by Invagination: A Case Report and Review of Literature. Am J Surg Case Reports. 2019. (License: CC Unspecified)
  12. Howship J. Practical Remarks on the Discrimination and Appearance of Surgical Disease. London, Churchill, 1840.
  13. Hannington-Kiff JG. Absent thigh adductor reflex in obturator hernia. Lancet. 1980 Jan 26;1(8161):180.
  14. Salameh JR. Primary and unusual abdominal wall hernias. Surg Clin North Am. 2008 Feb;88(1):45-60, viii.
  15. Stamatiou D, Skandalakis LJ, Zoras O, Mirilas P. Obturator hernia revisited: surgical anatomy, embryology, diagnosis, and technique of repair. Am Surg. 2011 Sep;77(9):1147-57.
  16. Kubo N, Yoshizawa Z, Hanaoka T, Nakamura K. A case of a perforated obturator hernia with a femoral abscess treated a pectineus muscle flap. BMC Surg. 2015 Oct 2;15:107. (License: CC BY 4.0)
  17. Lynch NP, Corrigan MA, Kearney DE, Andrews EJ. Successful laparoscopic management of an incarcerated obturator hernia. J Surg Case Rep. 2013 Jul 23;2013(7):rjt050. (License: CC BY-NC 3.0)