Double-Incision Surgical Management of Incarcerated Obturator Hernia Presenting With Acute Right Lower Abdominal Pain in a 67-Year-Old Woman

Introduction

An obturator hernia is a rare type of abdominal wall hernia, accounting for only 0.05% to 1.4% of all abdominal wall hernias, and 0.2% to 1.6% of cases of small-bowel obstruction [1–3]. This condition has the highest morbidity and mortality rates among all abdominal wall hernias, with reported mortality rates reaching 70% in cases complicated by strangulation or bowel necrosis [2,4,5]. The development of an obturator hernia is associated with multiple risk factors, including advanced age, female sex, low body mass index (BMI), multiparity, chronic illness, and increased intra-abdominal pressure due to conditions such as chronic constipation or pulmonary disease [2,4,6,7]. Considering that an obturator hernia is more likely to occur in elderly, chronically ill, and thin women, it is sometimes referred to as “the Little Old Lady Hernia” [2,3,7]. This is attributed to their wider pelvis, more triangular obturator canal, and reduced preperitoneal fat [2,3]. The clinical signs and symptoms of an obturator hernia are nonspecific, often mimicking other causes of abdominal or thigh pain, which frequently results in delayed diagnosis [2,3,5]. Although the Howship–Romberg sign may be present, it is not always reliable [3]. CT is currently considered the most accurate diagnostic tool, with over 90% sensitivity in experienced centers [2–5]. Early diagnosis and surgery can optimize outcomes [8]. Both open and laparoscopic approaches have been described, with laparoscopic repair offering reduced postoperative pain and shorter hospital stay in selected patients [4,6,9]. Various surgical methods describing the basic strategy of reducing the incarcerated intestine and fixing the obturator foramen have been reported in literature; however, no standardized surgical approach is universally accepted [3,4,6,9]. Notably, few reports discuss strategies for managing incarcerated intestines that cannot be reduced from the hernial sac back into the abdominal cavity by conventional means [1].

When faced with this challenge, we decided to use a 2-incision technique to solve the problem. This report presents the case of a 67-year-old woman with acute right lower abdominal pain due to an incarcerated obturator hernia managed with a double-incision approach, segmental bowel resection, and entero-enterostomy.

The Ethics Committee of Affiliated Huzhou Hospital, Zhejiang University School of Medicine approved the study, and informed written consent was obtained from the patient for publication of this case report and accompanying images.

Case Report

A 67-year-old frail woman (BMI 17.9 kg/m2) with a known history of cirrhosis, ascites, cholecystectomy, and chronic pulmonary infection presented to our Emergency Department with an 8-hour history of progressive right lower abdominal pain radiating to the right inner thigh and knee, accompanied by vomiting. She had recently been hospitalized in the Infectious Diseases Department for management of hepatic ascites, indicating a background of decompensated liver disease. At presentation, her vital signs were stable: temperature 36.7°C, heart rate 97 beats per minute, blood pressure 117/80 mmHg, respiratory rate 16 breaths per minute, and SpO2 99% on room air. On physical examination, the patient was alert and hemodynamically stable. Her abdomen was soft and non-distended, with no rebound tenderness or peritoneal signs. However, a tender, palpable mass was detected in the right groin. The right thigh was held in a flexed position, and passive abduction and external rotation elicited sharp pain. The neurological examination was unremarkable, but the Howship-Romberg sign was positive, suggesting possible obturator nerve irritation. Laboratory tests (Table 1) revealed mild anemia (hemoglobin 92.0 g/L), thrombocytopenia (platelets 72×109/L), and leukopenia (white blood cell count 3.0×109/L). Liver function tests showed elevated alanine aminotransferase (52.0 U/L), aspartate aminotransferase (4.6 U/L), and hypoalbuminemia (34.2 g/L). Electrolyte imbalances included hypokalemia (3.09 mmol/L), hypocalcemia (2.06 mmol/L), and hyperchloremia (113.6 mmol/L), consistent with hepatic dysfunction and ascites-related metabolic derangements. Abdominal ultrasonography revealed a mixed echogenic mass in the right inguinal region with absent peristalsis (Figure 1), suggesting a possible incarcerated hernia. A plain abdominal radiograph revealed dilated small-bowel loops with air-fluid levels, consistent with a mechanical small-bowel obstruction (Figure 2). These radiologic and clinical findings supported a diagnosis of mechanical intestinal obstruction secondary to an incarcerated obturator hernia. A contrast-enhanced CT scan performed 1 week earlier revealed cirrhosis, splenomegaly, significant ascites, and fluid collection between the right pectineus and external obturator muscles (Figure 3), confirming the anatomical site of the obturator hernia. Due to the patient’s decompensated cirrhosis and significant ascites, general anesthesia was considered high risk by the anesthesiology team. Therefore, emergency surgery was planned under local anesthesia with continuous intraoperative monitoring. With a working diagnosis of incarcerated obturator hernia complicated by suspected bowel strangulation, emergency surgery was initiated. A lower midline abdominal incision was made, revealing dilated small-bowel loops, but no hernial sac could be visualized through this approach. Multiple reduction attempts failed due to a narrowed obturator foramen, severe bowel edema, volvulus, and tight incarceration, which increased the risk of iatrogenic rupture (Figure 4). Therefore, an additional 4-cm groin incision was made directly over the projection site of the hernial sac (Figure 5). Upon opening the sac, approximately 16 cm of necrotic ileum was identified, confirming strangulation of the incarcerated bowel segment. The necrotic segment was resected, and an entero-enterostomy was performed using a stapled, side-to-side, isoperistaltic technique via the abdominal cavity. This approach was selected to ensure adequate luminal continuity and maintain physiologic peristaltic flow, particularly given the edema and fragility of the small bowel. The resected necrotic segment was then retrieved through the groin incision. Postoperative recovery was uneventful, and the patient was discharged in stable condition on postoperative day 10.

Although the CT scan revealed fluid accumulation near the left femoral canal, there were no clinical signs or symptoms of a left-sided hernia. Given her decompensated cirrhosis, ascites, and frailty, the surgical team used a limited open approach under local anesthesia, focused solely on the symptomatic right side. Therefore, exploration of the asymptomatic left side was deferred, acknowledging a small risk of a missed contralateral hernia. No postoperative complications or contralateral hernia were observed during follow-up.

Discussion

This case highlights the importance of early recognition and individualized surgical planning in cases of obturator hernia, particularly in elderly, emaciated women with bowel compromise. Obturator hernia is a rare form of pelvic hernia characterized by protrusion of abdominal contents through the obturator foramen, which is bordered by the pubis and ischium and covered by the obturator membrane [3]. This condition is more prevalent in elderly, emaciated, and multiparous women due to their broader pelvis and wider obturator canal, especially when accompanied by increased intra-abdominal pressure or chronic pulmonary disease [2,10,11]. Because the sigmoid colon anatomically shields the left obturator foramen, obturator hernias more frequently occur on the right side [2,10]. However, in our case, the hernia occurred on the left side, similar to the case reported by Gilbert et al [12], suggesting that left-sided obturator hernias, although less common, should not be overlooked, especially in emaciated women.

The clinical diagnosis is often challenging due to the lack of specific signs. Most patients present with symptoms of small-bowel obstruction such as nausea, vomiting, abdominal distension, and constipation [9,13]. Although rare, signs such as the Howship–Romberg sign or Hannington–Kiff sign can aid diagnosis when present, occurring in 15% to 50% of patients [12]. In our case, no typical neurologic signs were observed, and the initial presentation mimicked nonspecific gastrointestinal discomfort, consistent with prior reports of subtle or misleading symptoms in elderly patients [12,14]. Imaging plays a vital role in diagnosis, with CT scans being the most reliable modality for defining the hernia’s location, contents, and associated bowel compromise [2,15].

Surgical repair remains the only definitive treatment for incarcerated obturator hernia [6,16]. A variety of surgical approaches have been reported, including the abdominal, retropubic, obturator, and inguinal open approaches, as well as laparoscopic techniques [4]. Laparotomy is often preferred in emergency cases with suspected ischemia or necrosis, offering direct access for inspection, reduction, and resection [5,6]. In our case, due to the small and inelastic nature of the obturator foramen and extensive incarceration, a secondary inguinal incision over the hernia sac enabled safe decompression and resection of the necrotic bowel. This double-incision technique provided complementary exposure from both peritoneal and extraperitoneal sides, which is particularly beneficial in cases with tight incarceration or bowel compromise [17]. Although rarely reported, this approach offers a practical alternative when single-access reduction proves difficult, and can help avoid excessive traction or bowel rupture. While small abdominal incisions may limit exposure in cases of generalized ileus, our patient’s obstruction was due to an anatomically localized obturator hernia [2]. Based on preoperative imaging and clinical signs, we specifically targeted the obturator foramen via a lower midline incision. This approach was appropriate given the hernia’s defined location and allowed for initial exploration while minimizing unnecessary trauma. In contrast, for undifferentiated or diffuse small-bowel obstruction, a more extensive incision is necessary to ensure adequate visualization and treatment [2]. Our patient had no recurrence during follow-up, but clinicians should be aware that obturator hernia can recur, particularly when risk factors such as malnutrition or predisposing anatomy persist [18]. Laparoscopic repair techniques, particularly the transabdominal preperitoneal approach, have gained increased attention in recent years due to better visualization, less postoperative pain, and shorter recovery times [19,20]. However, the use of laparoscopy may be limited in cases with bowel necrosis, severe adhesions, or hemodynamic instability [2,5]. In such settings, open conversion or hybrid techniques like the one used in our case may be more appropriate.

After reduction, repairing the obturator defect is crucial. For clean, elective settings, mesh repair is generally recommended due to its low recurrence rate [4]. However, in contaminated fields – such as when perforation or necrosis is present – direct closure with nonabsorbable sutures is considered safer, with recurrence rates reportedly below 10% [21].

Conclusions

Obturator hernia remains a diagnostic and therapeutic challenge due to its rarity and nonspecific clinical presentation. Prompt diagnosis and emergency surgical intervention are critical to preventing bowel ischemia, necrosis, and potentially fatal complications. In cases where conventional reduction techniques fail or carry significant risk, a double-incision approach may allow for safe decompression, adhesiolysis, and resection. This case report contributes to the evolving understanding of flexible surgical strategies for managing complex obturator hernias.

Our patient’s poor general condition and intolerance to general anesthesia necessitated local anesthesia and a swift surgical procedure; therefore, traditional approaches like midline laparotomy or diagnostic laparoscopy were not feasible. The 2-incision technique was used to facilitate safe reduction and resection under these constraints, thereby minimizing intraoperative risk and improving postoperative outcomes.