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Special Feature |

Image of the Month—Diagnosis FREE

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Section Editor: S. Rozycki Grace, MD

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Arch Surg. 2007;142(6):572. doi:10.1001/archsurg.142.6.572.
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Published online

Exploratory laparotomy was performed. A left-sided obturator hernia was identified containing a segment of midjejunum. The hernia defect was approximately 1.5 cm (Figure 2). The hernia contents and peritoneal sac were reduced, and a necrotic segment of jejunum was resected. An extraperitoneal mesh repair was performed using a Surgisis Gold Hernia Repair Graft (Cook Biotech Incorporated, West Lafayette, Ind).

Place holder to copy figure label and caption
Figure 2.

Obturator canal with hernia defect.

Graphic Jump Location

Obturator hernia accounts for 0.2% to 0.4% of bowel obstructions. The obturator canal is the largest foramen in the pelvis and is located at the anterior superior border of the obturator foramen. Coursing through the canal are the obturator nerve, artery, and vein with preperitoneal fat. The hernia occurs frequently in elderly, debilitated women because of the loss of the protective fat pad.1,2The incidence is higher in women than men because of the broader pelvis and larger obturator canal.3,4Since the sigmoid colon acts as an anatomical barrier, right-sided herniations are more common.

Presenting symptoms are nonspecific and physical findings are usually vague.1Patients with a symptomatic obturator hernia often present with partial or complete bowel obstruction. Two classic signs have been associated with this type of hernia. Howship-Romberg sign is pain that extends down the medial aspect of the thigh with abduction, extension, or internal rotation of the knee due to irritation of the anterior division of the obturator nerve. It is present in 25% to 50% of patients.57Hannington-Kiff sign, which is more specific but less known, is ipsilateral loss of the thigh adductor reflex with preservation of the patellar reflex due to external nerve compression.8

Successful diagnosis can be achieved with high clinical suspicion and emergent CAT scan. A CAT scan appears to be the most valuable imaging modality aiding in the preoperative diagnosis and it is 100% accurate.7

Various surgical approaches, such as femoral, inguinal, and abdominal, have been reported in the literature. The abdominal approach is most favored since the preoperative diagnosis may be unclear and incidence of bowel compromise is high.7,9,10

Correspondence:Rodney J. Mason, MD, PhD, Department of Surgery, University of Southern California, 1200 N State St, 10850, Los Angeles, CA 90033 (rmason@surgery.usc.edu).

Accepted for Publication:June 28, 2006.

Author Contributions:Study concept and design: Estrada, Petrosyan, and Mason. Acquisition of data: Estrada, Petrosyan, and Mason. Analysis and interpretation of data: Estrada, Petrosyan, and Mason. Drafting of the manuscript: Estrada, Petrosyan, and Mason. Critical revision of the manuscript for important intellectual content: Estrada, Petrosyan, and Mason. Administrative, technical, and material support: Estrada, Petrosyan, and Mason. Study supervision: Estrada, Petrosyan, and Mason.

Financial Disclosure:None reported.

Bergstein  JMCondon  RE Obturator hernia: current diagnosis and treatment. Surgery 1996;119133- 136
PubMed Link to Article
Yip  AWAhChong  AKLam  KH Obturator hernia: a continuing diagnostic challenge. Surgery 1993;113266- 269
PubMed
Rogers  FA Strangulated obturator hernia. Surgery 1960;48394- 403
PubMed
Bjork  KJMucha  P  JrCahill  DR Obturator hernia. Surg Gynecol Obstet 1988;167217- 222
PubMed
Gray  SWSkandalakis  JESoria  RERowe  JS  Jr Strangulated obturator hernia. Surgery 1974;7520- 27
PubMed
Lo  CYLorentz  TGLau  PW Obturator hernia presenting as small bowel obstruction. Am J Surg 1994;167396- 398
PubMed Link to Article
Nakayama  TKobayashi  SShiraishi  K  et al.  Diagnosis and treatment of obturator hernia. Keio J Med 2002;51129- 132
PubMed Link to Article
Hannington-Kiff  JG Absent thigh adductor reflex in obturator hernia. Lancet 1980;1180
PubMed
Netter  FHIason  AHPansky  B Hernias. oppenheimer  EThe CIBA Collection of Medical Illustrations. Vol 3.Digestive System Part 2. Lower Digestive Tract. Summit, NJ CIBA Pharmaceutical Products1962;204- 230
Arbman  G Strangulated obturator hernia: a simple method for closure. Acta Chir Scand 1984;150337- 339
PubMed

Figures

Place holder to copy figure label and caption
Figure 2.

Obturator canal with hernia defect.

Graphic Jump Location

Tables

References

Bergstein  JMCondon  RE Obturator hernia: current diagnosis and treatment. Surgery 1996;119133- 136
PubMed Link to Article
Yip  AWAhChong  AKLam  KH Obturator hernia: a continuing diagnostic challenge. Surgery 1993;113266- 269
PubMed
Rogers  FA Strangulated obturator hernia. Surgery 1960;48394- 403
PubMed
Bjork  KJMucha  P  JrCahill  DR Obturator hernia. Surg Gynecol Obstet 1988;167217- 222
PubMed
Gray  SWSkandalakis  JESoria  RERowe  JS  Jr Strangulated obturator hernia. Surgery 1974;7520- 27
PubMed
Lo  CYLorentz  TGLau  PW Obturator hernia presenting as small bowel obstruction. Am J Surg 1994;167396- 398
PubMed Link to Article
Nakayama  TKobayashi  SShiraishi  K  et al.  Diagnosis and treatment of obturator hernia. Keio J Med 2002;51129- 132
PubMed Link to Article
Hannington-Kiff  JG Absent thigh adductor reflex in obturator hernia. Lancet 1980;1180
PubMed
Netter  FHIason  AHPansky  B Hernias. oppenheimer  EThe CIBA Collection of Medical Illustrations. Vol 3.Digestive System Part 2. Lower Digestive Tract. Summit, NJ CIBA Pharmaceutical Products1962;204- 230
Arbman  G Strangulated obturator hernia: a simple method for closure. Acta Chir Scand 1984;150337- 339
PubMed

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