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Purpose: Non-invasive reduction in patients with incarcerated obturator hernias is an emergency surgery alternative. There are two non-invasive reduction types: manual and ultrasonographic (ultrasound-guided and ultrasound-assisted reduction). However, the impact of ultrasound guidance on manual reduction has not been adequately evaluated. We aimed to compare non-invasive ultrasound reduction with manual reduction in patients with incarcerated obturator hernias., Methods: We searched MEDLINE, Cochrane Central Library, Embase, Ichushi Web, ClinicalTrial.gov, and ICTRP for relevant studies. The primary outcomes were success and bowel resection rates. We performed a subgroup analysis between ultrasound-guided and ultrasound-assisted reductions. This study was registered in PROSPERO (CRD 42,024,498,295)., Results: We included six studies (112 patients, including 12 from our cohort). The success rate was 78% (69 of 88 cases) with ultrasonographic reduction and 33% (8 of 24 cases) with manual reduction. The success rate was higher with ultrasonographic than with manual reduction. Subgroup analysis revealed no significant difference between ultrasonography-assisted (76%) and ultrasonography-guided (80%) reductions (p = 0.60). Non-invasive reductions were predominantly successful within 72 h of onset, although durations extended up to 216 h in one case. Among the successful reduction cases, emergency surgery and bowel resection were necessary in two cases after 72 h from onset. Bowel resection was required in 48% (12 of 25), where the non-invasive reduction was unsuccessful within 72 h of confirmed onset., Conclusions: Ultrasonographic reduction can be a primary treatment option for patients with obturator hernias within 72 h of onset by emergency physicians and surgeons on call. Future prospective studies are needed to evaluate ultrasonographic reduction's impact., (© 2024. The Author(s).)

Obturator hernia (OH) is a rare and dangerous disease that can lead to life-threatening consequences, and pelvic computed tomography (CT) is widely used for its diagnosis. There is no consensus regarding the surgical approach and repair methods. Retrospective analysis of the clinical and follow-up data of 15 cases of incarcerated hernias patients admitted to the Department of General Surgery, affiliated to Taicang Affiliated Hospital of Soochow University, from January 2011 to December 2022. OH could be precisely diagnosed with pelvic CT scan, except for occult OH and non-strangulated OH. Thirteen patients underwent emergency surgery, with a total complication rate of 76.9% and no mortality. Ten patients underwent open surgery, and 3 patients underwent laparoscopic surgery, which had advantages in terms of total cost and postoperative hospital stay (P < .05). Emergency patients all underwent simple peritoneal closure, and hernial sac excision was simultaneously performed in 6 of them. A recurrence (7.7%) was detected at 38 months after the first operation. There was no statistically significant difference between the 2 tissue repair methods in terms of recurrent rate. Pelvic CT can be used as a gold standard for the diagnosis of incarcerated OH, but it has limited value in occult OH and non-strangulated OH. Laparoscopic surgery is recommended for patients with a short onset time and no abdominal physical signs. Tissue repair is sufficient for incarcerated OH and hernial sac excision may be unnecessary., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: This study aimed to determine the occurrence of incidental obturator hernia and clinical risk factors of their appearance in patients undergoing totally extraperitoneal (TEP) inguinal hernioplasty., Methods: Data were collected retrospectively from patients who underwent TEP inguinal hernioplasty between June 2020 and December 2022., Results: A total of 251 patients were included in the study. Obturator hernias were found in 21 patients (8.4%). At admission, no patient presented clinical signs of an obturator hernia. There was a significant predominance of women in the obturator hernia compared to the non-obturator hernia group (28.6% vs. 10.9%, respectively, p=0.018). There was no correlation between age (p=0.479) and BMI (p=0.771) and the occurrence of obturator hernia. Additional obturator hernia repair within the TEP inguinal hernioplasty procedure did not influence the overall length of the surgery (60.86 minutes) compared to the standard TEP inguinal hernioplasty (61.09 minutes, p=0.876)., Conclusions: The TEP inguinal hernioplasty allows the detection and repair of incidental obturator hernia. Through thorough inspection of the obturator canal, an asymptomatic obturator hernia can be detected and adequately treated within the same procedure, without the impact on the surgery duration, when performed by an experienced hernia surgeon., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Concurrent direct and indirect inguinal, femoral, and obturator hernias are rare. This case report describes a rare case treated using the laparoscopic approach. A 68-year-old female patient presented with a moving left inguinal lump and pain. Physical examination and abdominal computed tomography scan revealed the coexistence of a left inguinal hernia or Nuck canal hydrocele and a left femoral hernia. The patient underwent laparoscopic transabdominal preperitoneal repair, and all four orifices were covered with one mesh. The patient was discharged on the second postoperative day without any complications. The concurrent presence of four hernias on the same side is rare and has not been previously reported. The laparoscopic approach is useful in such cases because it allows visualization of multiple hernia orifices from the intra-abdominal cavity., (© 2024 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

The current study aimed to identify the indications for manual reduction in incarcerated obturator hernias (OH). Further, whether time to symptom onset and manual reduction outcomes can be predictors of bowel viability and the need for bowel resection in incarcerated OH were examined. This retrospective study included 26 patients with incarcerated OH who underwent surgery. All patients underwent manual reduction, and computed tomography scan after manual reduction confirmed hernia release. Multivariate analyses were performed to determine the predictors of bowel resection. The bowel resection group had a significantly longer average time to symptom onset than the nonbowel resection group (88 vs 36 h). Further, the bowel resection group was more likely to have failed manual reduction than the nonbowel resection group. A time to symptom onset of ≥ 72 h and failed manual reduction were significant predictors of bowel viability. Age, sex, hernia localization, American Society of Anesthesiologists physical status score, and laboratory findings did not differ significantly between the bowel resection and nonbowel resection groups. Time to symptom onset and manual reduction outcomes are significant predictors of bowel viability in incarcerated OH. Patients with a time to symptom onset of ≥ 72 h and failed manual reduction require surgical evaluation due to a high risk of bowel nonviability. Therefore, a cautious approach is required in the management of OH, and further research on optimized treatment protocols should be conducted., (© 2024. The Author(s).)

Obturator hernia is a rare condition that commonly affects frail older women. A 54-year-old woman presented to our hospital with left hip joint pain. She had suffered a left pubic bone fracture and commenced maintenance hemodialysis. Pelvic computed tomography (CT) showed an incarcerated small intestine through the left obturator foramen, while abdominal CT showed marked intestinal dilatation. She underwent emergency laparotomy, and the incarcerated small intestine was found to be necrotic. Partial small intestinal resection and bilateral obturator hernioplasty were performed. Because obturator hernia is a potentially fatal condition, early detection and treatment are important.

Purpose: We aimed describe the patient characteristics, surgical details, postoperative outcomes, and prevalence and incidence of obturator hernias. Obturator hernias are rare with high mortality and no consensus on the best surgical approach. Given their rarity, substantial data is lacking, especially related to postoperative outcomes., Methods: The study was based on data from the nationwide Danish Hernia Database. All adults who underwent obturator hernia surgery in Denmark during 1998-2023 were included. The primary outcomes were demographic characteristics, surgical details, postoperative outcomes, and the prevalence and incidence of obturator hernias., Results: We included 184 obturator hernias in 167 patients (88% females) with a median age of 77 years. Emergency surgeries constituted 42% of repairs, and 72% were laparoscopic. Mesh was used in 77% of the repairs, with sutures exclusively used in emergency repairs. Concurrent groin hernias were found in 57% of cases. Emergency surgeries had a 30-day mortality of 14%, readmission rate of 21%, and median length of stay of 6 days. Elective surgeries had a 30-day mortality of 0%, readmission rate of 10%, and median length of stay of 0 days. The prevalence of obturator hernias in hernia surgery was 0.084% (95% CI: 0.071%-0.098%), with an incidence of one per 400,000 inhabitants annually., Conclusions: This was the largest cohort study to date on obturator hernias. They were rare, affected primarily elderly women. The method of repair depends on whether the presentation is acute, and emergency repair is associated with higher mortality., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Obturator Hernia (OH) is a rare type of abdominal wall hernia. It usually occurs in elderly women with late symptomatic presentation, increasing mortality rates. Surgery is the standard of care for OH, and laparotomy with simple suture closure of the defect is commonly used. Given the rarity of this disease, large studies are lacking, and data to drive management are still limited. This systematic review and meta-analysis aimed to describe current surgical options for OHs, with a focus on comparing the effectiveness and safety of mesh use with primary repair., Methods: PubMed, EMBASE, and Cochrane were searched for studies comparing mesh and non-mesh repair for OH. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4., Results: One thousand seven hundred and sixty studies were screened and sixty-seven were thoroughly reviewed. We included 13 observational studies with 351 patients surgically treated for OH with mesh or non-mesh repair. One hundred and twenty (34.2%) patients underwent mesh repair and two hundred and thirty-one (65.81%) underwent non-mesh repair. A total of 145 (41.3%) underwent bowel resection, with the majority having a non-mesh repair performed. Hernia recurrence was significantly higher in patients who underwent hernia repair without mesh (RR 0.31; 95% CI 0.11-0.94; p = 0.04). There were no differences in mortality (RR 0.64; 95% CI 0.25-1.62; p = 0.34; I 2  = 0%) or complication rates (RR 0.59; 95% CI 0.28-1.25; p = 0.17; I 2  = 50%) between both groups., Conclusion: Mesh repair in OH was associated with lower recurrence rates without an increase in postoperative complications. While mesh in clean cases is more likely to offer benefits, an overall recommendation regarding its use in OH repair cannot be made due to potential bias across studies. Given that many OH patients are frail and present emergently, the decision to use mesh is complex and should consider the patient's clinical status, comorbidities, and degree of intraoperative contamination., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Obturator hernias are quite rare in the world of hernias, and one that contains an acutely inflamed appendix becomes a very rare case indeed. An obturator hernia containing the appendix has been reported only 5 times in the surgical literature. Three of those cases were in elderly women with delayed presentations and were fatal. The most recent case was in a young woman with prompt laparoscopic appendectomy and no complications. We present a case in a 25-year-old man presenting with acute appendicitis and found to be incarcerated within the obturator canal during laparoscopy. The patient was treated with a 4-day course of postoperative antibiotics and a surgical drain that was later removed who had a full recovery. We conclude that the appropriate workup includes CT imaging and treatment with laparoscopic surgery for removal of the appendix.

Emergent surgery is a common approach for incarcerated obturator hernias, with high morbidity and mortality rates. Moreover, there have been reports of elective surgery cases after noninvasive manual reduction. For a decade, the initial approach in our institution is also manual reduction unless bowel viability is poor. This study aimed to clarify the efficacy and safety of manual reduction followed by elective surgery. We retrospectively reviewed 50 cases of incarcerated obturator hernia from 2010 to 2022 at Iwate Prefectural Iwai Hospital. Manual reduction was attempted in 31 (62%) patients. The reduction was successful in 21 (42%) patients, and most of them received mesh repair using the extraperitoneal approach as elective surgery. However, two patients underwent emergent surgery in the waiting period because of late-onset constriction and a small bowel perforation. Patients with irreducible hernia underwent emergent surgery, except for two patients who received the best supportive care. Postoperative complications were observed in 5% and 22% of reducible and irreducible cases, respectively. Postoperative mortality was zero in both groups. Manual reduction is useful in some cases, but careful observation is needed because late-onset constriction and perforation could occur., (© 2023. The Author(s).)

To evaluate the effectiveness of 4-hand reduction for obturator hernia with the guidance of sonography (FROGS) as a new treatment strategy for obturator hernia. Since November 2019, FROGS was performed for all patients with obturator hernia at our emergency department. We retrospectively compared the clinical data of 20 patients who underwent FROGS (after FROGS group) to those of 23 patients who did not (before FROGS group). All patients except one were female. The male-to-female ratio, age, duration of symptoms, lesion site, and predisposing factors did not significantly differ between groups. However, the diameter of the prolapsed bowel and the body mass index of the after FROGS group were significantly larger and lower, respectively. Manual reduction was successfully performed for all 20 patients in the after FROGS group, and bowel resection was avoided for all 20 cases. However, 14 patients in the before FROGS group underwent manual reduction; of these, only one was successfully treated using a method other than FROGS, and 8 patients underwent bowel resection. There were no significant differences between groups in terms of postprocedural complications or mortality within 30 days of hernia presentation. The FROGS technique was safe and reproducible and could be used as the first choice of treatment for patients with obturator hernia., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

An 85 year-old woman was transferred with a chief complaint of right thigh pain persisting for 5 days. Abdominal contrast-enhanced computed tomography clearly depicted a swollen appendix incarcerated in the right obturator cavity. She underwent an emergent laparoscopic appendectomy and the simultaneous repair of the obturator hernia. At laparoscopy, appendix was found to be incarcerated in the right obturator canal. The incarcerated appendix was successfully flushed out from the sac by spurting saline into the obturator hernia sac through the catheter inserted into the hernia sac. After a laparoscopic appendectomy, the hernia orifice was repaired using the uterine flap. The patient was discharged from the hospital without any sequelae. This report demonstrates a very rare case of obturator hernia incarcerated with appendix. Although patients with obturator hernia incarcerated with small intestine present with the symptoms related to bowel obstruction, patients with incarceration of appendix do not. Moreover, they would show no typical abdominal symptoms associated with acute appendicitis. Therefore, it is important to perform a radiological evaluation promptly to make a definitive diagnosis when a patient with persisting pain of the right thigh or right ileac fossa with a possibility of obturator hernia with incarceration of the appendix is encountered., (© 2022. Japanese Society of Gastroenterology.)

Background: Obturator hernia is an infrequent pelvic hernia observed in elderly, emaciated and multiparous women. It often presents with nonspecific clinical symptoms, making it difficult to diagnose., Methods: We conducted a retrospective descriptive study on 11 patients admitted to our hospital for obturator hernia from 2009 to 2020., Results: All the patients were diagnosed with intestinal obstruction due to incarcerated obturator hernia preoperatively. Eight patients underwent laparotomy with low midline incision. Laparoscopic approach was tried on the other three patients with two patients converting to open surgery because of inadequate visualization, and only one patient received laparoscopic repair. Of the 10 patients receiving laparotomy, seven cases received obturator hernia repair with a match and three cases were subjected to bowel resection (two cases intestinal necrosis and one case intestinal perforation). Simple peritoneal closure was performed on the three contaminated cases. One patient died of septic shock and multiple organ failure., Conclusion: The emergent computed tomography allow for early and precise diagnosis of incarcerated obturator hernia. Laparotomy with low midline incision is commonly used to manage obturator hernia in an emergency, whereas laproscopic approach may only apply to some selected cases., (© 2022 Royal Australasian College of Surgeons.)

Competing Interests: Competing interests: None declared.

Purpose: The purpose of this study was to explore the feasibility and potential advantages of laparoscopic surgery in the treatment of incarcerated obturator hernia (IOH)., Materials and Methods: Clinical data of 23 patients with IOH who underwent emergency surgery at our hospital from June 2015 to October 2020 were retrospectively analyzed. The clinical characteristics and surgery outcomes were compared between the laparoscopic group, open group, and the previously published data., Results: Twelve patients with IOH were treated by laparoscopic management, while 11 patients with IOH underwent open surgery. There was no statistically significant difference in preoperative general data between the 2 groups, while the laparoscopic group had less intraoperative blood loss, shorter postoperative hospital stay, and lower postoperative complications compared with open group. Furthermore, when compared with the open group reported in previous literature, which showed similar conclusions., Conclusion: Laparoscopic surgery for IOH showed more favorable advantages including less intraoperative blood loss, shorter postoperative hospital stay, and lower postoperative complications compared with an open approach, which is a safe and feasible minimally invasive strategy and has certain advantages., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Bowel wall enhancement on CT imaging is considered one of the useful features for the prediction of the presence of irreversible ischemic change in patients with small bowel obstruction. However, the applicability of CT imaging in patients with incarcerated hernias has not been investigated in detail. The aim of this retrospective study was to evaluate the feasibility of preoperative CT findings for the prediction of the presence of irreversible ischemic change in patients with incarcerated hernias containing small bowel., Methods: Included in this study were 76 patients who underwent surgery for preoperatively diagnosed incarcerated hernias containing small bowel (27 inguinal hernias, 37 femoral hernias and 12 obturator hernias) at our hospital between January 2011 and June 2020. The preoperative clinicoradiological features were compared between the groups, and predictors for intestinal resection were evaluated., Results: Nineteen patients required intestinal resection (Resection group), and the other 57 patients did not require intestinal resection (Nonresection group). Multivariate analyses revealed that age ≥ 80 years (p = 0.018, odds ratio = 6.604) and the absence of bowel wall enhancement (p = 0.032, odds ratio = 51.200) were independent predictors for intestinal resection. In resected specimens, all patients with an absence of bowel wall enhancement on preoperative enhanced CT had ischemic changes extending beyond the muscularis propria., Conclusions: Preoperative enhancement CT yields useful information for the prediction of the presence of irreversible ischemic change in patients with incarcerated hernias containing small bowel., (© 2020. Springer-Verlag France SAS, part of Springer Nature.)

Background: Obturator hernias are rare and associated with high mortality. However, the optimal surgical approach remains unknown. We aimed to investigate the available evidence and examine the surgical details regarding obturator hernia defect closure as well as the recurrence rates of the different approaches., Methods: We reported this scoping review according to the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analysis Extension for Scoping Reviews) and registered the protocol online. A comprehensive literature search in five different databases was conducted. The population was patients undergoing surgery for obturator hernia. Articles were included for data charting if the management of the hernia defect was reported. Data regarding surgical details, and hernia recurrence were extracted., Results: A total of 1299 patients from 313 articles were included. In total, 937 patients underwent open obturator hernia repair, in which 992 hernias were repaired (including some bilateral obturator hernias). A total of 295 patients underwent laparoscopic repair for 341 obturator hernias, and for the remaining 67 patients, type of surgery was not reported. For open surgery, suture repair was the most common method of repair (n = 508, 51%) with a recurrence rate of 10%. For laparoscopic surgery, the most common repair of the defect was mesh repair (n = 299, 88%) with no reported recurrences., Conclusion: Open surgery with primary suture repair is the most common method of repair for obturator hernia but is associated with a recurrence rate of 10%. Laparoscopic mesh repair is becoming more common and have seemingly very low recurrence rates and may be a better method of repair., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

BACKGROUND Obturator hernia is an uncommon (0.07-1% incidence rate) subtype of hernia of the abdominal wall, with its incarceration being a rare cause of bowel obstruction. Obturator hernia has a higher incidence in elderly women and in malnourished people. This type of hernia has the highest morbidity and mortality rates of all abdominal wall hernias. This article reports a case of an emaciated 93-year-old woman who presented with small bowel obstruction due to incarcerated obturator hernia, successfully managed surgically with a modified mesh-plug hernioplasty. CASE REPORT An emaciated 93-year-old woman presented with diffuse abdominal pain, more intense on the right iliac fossa, radiating to the right thigh, with 8-h evolution and associated with dark-colored vomiting but normal bowel transit. This patient had a surgical history of right Richter´s femoral hernia, strangulated, with previous intestinal resection and a right femoral hernioplasty. A computed tomography (CT) scan revealed an incarcerated obturator hernia on the right side containing a short segment of small intestine. The patient underwent an exploratory laparotomy and a mesh-plug hernioplasty. During follow-up, there was no evidence of recurrence or complications. CONCLUSIONS Obturator hernia diagnosis is challenging due to its rarity and its signs and symptoms being often unspecific. CT scan has the highest sensitivity and is the best diagnostic tool. Surgical management is the only possible treatment for obturator hernia. Awareness of this condition is essential to allow an earlier approach and attempt to mitigate the associated high morbidity and mortality rates.

In surgery for incarcerated hernia, intestinal blood flow is an important factor in intraoperative decision-making given that irreversible ischemia can result in intestinal necrosis. Here, we report a case of incarcerated obturator hernia in which the bowel was successfully preserved by evaluating intestinal blood flow with the indocyanine green fluorescence imaging method. A woman in her 80s was diagnosed with incarcerated right obturator hernia, and a laparoscopic operation was performed. The small bowel tissue that had been incarcerated exhibited dark red discoloration. Fluorescence examination of the bowel wall indicated that the ischemic changes were reversible, and accordingly, the bowel was not resected. The postoperative course was uneventful. The indocyanine green fluorescence imaging method is a useful new source of evidence that will improve intraoperative decision-making regarding bowel ischemia., (© 2020 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Background: Obturator hernia is a rare pelvic hernia associated with a high morbidity and mortality. It most commonly occurs in elderly, multiparous females with symptoms and signs of small bowel obstruction. We present an Australian hospital network experience on emergency presentations of obturator hernias highlighting differences between clinical profile and surgical management., Methods: A retrospective review of adult patients diagnosed with acute obturator hernia during a 10 year period (2010-2020) was conducted across 10 major Sydney hospitals in New South Wales, Australia., Results: Obturator hernia was diagnosed in 18 patients (mean 82.7 years, range: 60-96 years old), all confirmed on pre-operative computed tomography imaging. The most common presentations were elderly women demonstrating clinical features of a small bowel obstruction. The mean onset of symptoms from home to hospital admission was 49.4 h. Non-survivors had a significantly elevated urea level (15.6 vs. 7.8 mmol/L, p = 0.036) at presentation and a longer delay from onset of presenting symptoms to diagnosis (84.0 vs. 36.2 h, p = 0.028). Eleven patients underwent urgent laparotomy and six laparoscopic repairs. The mean operative time was 101.0 min. The average hospital length of stay was 16.2 days with a mortality rate of 27.8%., Conclusion: Timely diagnosis and operative intervention for obturator hernia is the cornerstone of management., (© 2021 Royal Australasian College of Surgeons.)

Background: Ureteral obturator hernia is a rare condition, usually found accidentally during imaging examinations, or found during surgery. Ureteral hernia can easily lead to ureteral obstruction and hydronephrosis. Long-term hydronephrosis may lead to kidney damage and infection, and eventually cause kidney failure. As of December 31, 2020, there are only 2 literature reports., Case Presentation: This article reports a 67-year-old female patient with no symptoms. The computed tomography (CT) scan of the urinary system to show the left kidney and ureter had hydrops. The CTU imaging of the urinary tract revealed the left ureter pelvis herniated into the parietal pelvic fascia was accompanied by tortuosity and left hydronephrosis. She underwent laparoscopic abdominal wall hernia repair on April 29, 2020, and she recovered well., Conclusions: Ureteral obturator hernia is an uncommon condition. The clinical symptoms are non-specific, including unclear abdominal pain, until the appearance of obstructive diseases of the urinary tract, such as renal insufficiency, urinary tract infection, kidney stones, and uremia. A comprehensive review of the literature shows that it is difficult to make an accurate diagnosis based on physical examination alone.Early urography can improve the possibility of accurate diagnosis. When a patient suffers from impaired renal function, timely surgical treatment can avoid deterioration of renal function.

Aim: Presenting an extraordinary cause of intestinal obtuction, leading to incarcerated obturator hernia., Case Report: We present a rare case of obturator hernia in a 90-year-old female, who presented with a three-day history of inability to defecate and abdominal pain, distension, and vomiting on the day of presentation. Hours later, a computed tomography scan revealed a bowel obstruction secondary to a right-sided obturator hernia. She underwent an emergency exploratory laparotomy and the incarcerated bowel was reduced with a repairment of the hernial defect. The patient demonstrated an uneventful postoperative period and was discharged on hospital day four., Discussion: Obturator hernia, a rare anterior abdominal wall hernia, in which abdominal contents protrude through the obturator canal, is an unusual cause of intestinal obstruction. It has one of the highest mortality rates of all abdominal wall hernias with a challenging diagnosis that can still be misleading even to the most experienced surgeons., Conclusion: Providers should be aware of inability to defecate, abdominal pain, distension, and vomiting that may be due to an existence of incarcerated/strangulated obturator hernia, thus the further evaluation should be considered as the elements of the clinical picture are incongruent., Key Words: Emergencies, Hernia, Intestines, Intestinal obstruction, Obturator.

Background: To explore the clinical characteristics, diagnosis and treatment of obturator hernia., Methods: Eighty-six patients who were diagnosed as obturator hernia by abdominal CT in the Department of Gastrointestinal Surgery of our hospital between 2009 and 2019 were enrolled in this study. Patient characteristics, surgical method, postoperative complications and mortalities were retrospectively reviewed., Results: Thirty days mortality rate of 5.5% and 46.1% were observed in surgery group and non-surgery group, respectively. Surgery was performed as an emergency procedure in 59 cases and elective procedure in 14 cases depending on different hernia contents, intestinal necrosis and signs of peritonitis. In the emergency surgery group, segmental intestinal resection with anastomosis was performed in 24 patients (24/59, 40.7%). There were 4 deaths (4/59, 6.8%) in this group, all of which occurred in patients undergoing SI resections. In contrast, no bowel resection, postoperative complications, or death occurred in the elective surgery group. 3-year recurrence rates of 5.1% (3/59) and 7.1% (1/14) were observed in the emergency surgery and the elective surgery group, respectively., Conclusions: CT examination plays an important role in improving the diagnostic rate of obturator hernia. Timely surgical treatment is the key to improve the efficacy of obturator hernia and prevent the deterioration of the condition. In addition, intestinal resection and postoperative complications may be the important factors leading to postoperative death.

Purpose: Obturator hernias (OH) are extremely rare hernias, accounting for 0.07-1% of all hernias. This is the first systematic review investigating their presentation, imaging, treatment outcomes, and recurrence rate., Methods: After a detailed search in electronic search engines, 74 studies matched our criteria. A review of these reports was conducted and the full texts were examined., Results: A total of 146 patients with a mean age of 78.8 years were included in our analysis, with 40.1%, 29.9%, and 25.2% of patients suffering from either a right, a left or bilateral OH, respectively. OH were associated with non-specific symptoms and signs; bowel obstruction being the most common. Howship-Romberg sign was present in 56.2% of patients. Computed tomography (CT) scan was the most frequently used diagnostic modality, inversely associated with perioperative mortality. Mesh repair demonstrated a significantly improved perioperative morbidity rate, compared with non-mesh repair. Approximately 30% of patients underwent a laparoscopic operation, which was associated with significantly decreased morbidity and mortality rate as well as length of hospital stay, compared with the open repair., Conclusion: OHs are not associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair.

An 85-year-old malnourished woman presented with symptoms of small bowel obstruction of uncertain aetiology. She had presented numerous times over the previous 2 years with symptoms of left groin and thigh pain, vomiting and abdominal distension. A CT of her abdomen and pelvis ultimately revealed a left-sided pelvic hernia, between the obturator internus and pectineal muscles. This was consistent with an obturator hernia. Diagnostic laparoscopy confirmed an obturator hernia of Richter type, incarcerated within the left obturator canal. Reduction revealed a hernia sac containing viable small bowel. A primary repair was performed using a double-layer suture technique to both close and plug the hernia defect. The patient rapidly recovered following hernia repair, with resolution of all previous long-standing symptoms. This case exemplifies the typical presentation of an obturator hernia and the diagnostic challenge it poses to clinicians., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Obturator hernia is a relatively rare type of abdominal hernia, in which abdominal contents protrude through the obturator canal, a condition that can lead to small bowel obstruction. Its rarity and nonspecific signs and symptoms make a preoperative diagnosis difficult. The present study analyzed the clinical manifestations, diagnostic methods and operative treatment outcomes in patients with obturator hernia.Between January 2012 and October 2019, 1028 adults underwent surgical repair of abdominal wall hernia at the Department of Surgery, Kyungpook National University Hospital. The medical records of eleven patients who were treated for small bowel obstruction due to obturator hernia were retrospectively evaluated. Patient characteristics, clinical presentation, preoperative radiological diagnosis, operative findings, treatment, complications, and outcomes were recorded.All 11 patients were elderly women, with a mean age of 80.2 years (range, 71-87 years). Their mean body mass index was 17.9 kg/m (range, 11.9-22.2 kg/m). Symptoms at presentation were abdominal pain and vomiting, with a mean duration of symptoms prior to admission of 5.6 days (range, 1-15 days). Based on abdominopelvic computed tomography (CT) scans, all 11 patients were preoperatively diagnosed with obturator hernia, followed by laparoscopic exploration or laparotomy as soon as possible. Of the 11 patients, 6 (54.5%) had left-sided, four (36.4%) had right-sided, and one (9.1%) had bilateral obturator hernias. Three patients (27.3%) required resection of the ileum due to perforation or strangulation. All underwent simple closure of the hernia defect with interrupted or purse-string sutures. Ten patients recovered uneventfully, whereas one had wound seroma and ileus. Recurrence has not been observed in the 8 surviving patients.Obturator hernia should be included in the differential diagnosis of intestinal obstruction of unknown origin, especially in emaciated elderly women with chronic disease. Early surgical intervention without delay is imperative to avoid postoperative morbidity and mortality associated with intestinal strangulation due to obturator hernia. Obturator hernia can be sufficiently repaired with simple suture closure without mesh.

Background: We examined the validity and applicability of the Kugel repair approach for obturator hernias, whereby we placed a Kugel patch through the preperitoneal space after placing a short 5-cm skin incision just medial to the anterior iliac spine and 2 cm cranial to the expected origin of the internal inguinal ring., Methods: We studied patients who underwent surgical Kugel repair for obturator hernias at the Department of General Surgery, Saitama Medical University between 2007 and 2017. We examined the operating time, length of hospital stay, postoperative complications, and mortality rate., Results: Fifty-eight patients with obturator hernias presented with symptoms of small bowel obstruction. A Kugel approach was used in 53 patients and a midline approach was used in 5 patients with preoperative peritonitis. Of the 53 patients managed using the Kugel approach, 39 did not require intestinal resection; a mesh was used in all these patients. In the remaining 14 patients, intestinal resection was required and performed using the same approach; subsequently, a mesh was used successfully in 6 of these 14 patients. The overall median operating time was 47 min; the corresponding values for procedures with and without intestinal resection were 39 and 68 min, respectively. In terms of postoperative complications, operative mortality was not noted among patients without intestinal perforation; however, superficial surgical site infection developed in 2 patients. Among the 5 patients with preoperative peritonitis who underwent exploratory laparotomy via a midline incision, intestinal perforation was detected during surgery, and all patients required intestinal resection; none of the patients had received a mesh, and 2 patients died after surgery., Conclusions: The Kugel repair approach was possible even in patients with obturator hernia requiring intestinal resection. However, for patients with perforations, open surgery should be performed after securing the surgical field through a midline incision.

Here, we present a novel surgical technique to repair an obturator hernia with a uterine flap. The description is both written and in video format., (© 2019 Royal Australasian College of Surgeons.)

A case of two-stage minimally invasive surgical treatment of an elderly patient with bilateral inguinal hernia is presented: a recurrent oblique on the left, combined (femoral, obturator, oblique and direct inguinal) on the right with incarceration and necrosis of the small intestine in the femoral canal. Previously, the patient underwent closure of perforated ulcer of duodenum from upper-midline laparotomy, epicystostomy, transvesical adenomectomy from the lower-midline laparotomy. The first stage we performed diagnostic laparoscopy, minilaparotomy, reduction and resection of necrotic small intestine loop. The second stage was carried endovideoscopic total extraperitoneal allohernioplasty by the method of Extended-View Totally Extraperitoneal (e-TEP) on two sides. The positive results of the treatment indicate a high efficiency of video endoscopic alloplasty of occult hernias in a complex case. To diagnose and perform adequate surgical intervention with a combined femoral hernia, when the obturator and inguinal hernias are formed, but clinically do not manifest themselves, it is possible only with endoscopic examination of potential sites of hernia formation in the inguinal region, which is not possible with open plastic hernia of the inguinal region.

Competing Interests: Competing interests: None declared.

Groin pain is a common complaint in the general population, with an underlying etiology that may be difficult to diagnose. Although uncommon, type I obturator hernias may be a significant source of chronic or refractory groin pain. In this review, we discuss the commonly missed findings of type I obturator hernias at CT and MRI, as well as correlate these findings with images obtained at the time of laparoscopic repair., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Management strategies for acutely incarcerated/strangulated groin and obturator hernias may differ from institution to institution, although, conventionally, the open approach has been used. Recently, laparoscopic transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair have become commonly used operative procedures for the repair of groin hernias. It is unclear whether laparoscopic reduction and herniorrhaphy can be successfully accomplished in all cases. This study was aimed at assessing the effectiveness of laparoscopic treatment. Methods: We conducted a prospective clinical trial of the laparoscopic approach from December 2011 and comparatively analyzed the surgical outcomes between the open and laparoscopic approaches for incarcerated/strangulated hernias seen from December 2000 to March 2017. Results: The open approach for repair was used in 54 patients (50.9%) and the laparoscopic approach in 52 patients (49.1%). There was 1 case in which from the laparoscopic approach to laparotomy (1.9%) was required. The operation time treated by the laparoscopic approach was significantly longer than the open approach (126.4 minutes versus 104.6 minutes; P  = .0079); however, the incidence of postoperative complications and the postoperative length of hospitalization were also less in the former group than in the latter group (3.9% versus 18.5%; P  = .0172 and 5.6 days versus 14.7 days; P  = .0096). Second-stage TAPP herniorrhaphy was performed in 7 patients (15.2%) after bowel resection or closure of bowel perforation, and first-stage TEP herniorrhaphy was performed in 1 patient after bowel resection. There was no case of mesh infection in the group treated by the laparoscopic approach, and there was 1 case of mesh infection in the group treated by the open approach. The mortality rate was 0% in the group treated by the laparoscopic approach. Conclusions: Laparoscopic reduction and herniorrhaphy for acutely incarcerated/strangulated groin and obturator hernias is effective, safe, and feasible.

Purpose: The purpose of this study was to identify any potential correlation between postoperative mortality and bowel resection in patients with obturator hernias., Methods: In total, 21 patients who underwent emergency surgery for a primary incarcerated obturator hernia during a 9-year period were retrospectively assessed regarding the correlation between postoperative mortality within 30 days from surgery and bowel resection., Results: The 21 hernias occurred in 20 women and 1 man. The mean age at presentation was 83.3 years. Eight hernias required bowel resection, and operations using mesh were performed for eight hernias. Complications occurred in association with nine hernias, and three patients died. Postoperative mortality was correlated with complications (p = 0.016) and bowel resection (p = 0.010). Patients undergoing bowel resection had a significantly longer operation time (p = 0.009) and a higher rate of postoperative complications (p = 0.018). The systolic blood pressure, pH, and base excess were significantly lower in patients who did than did not undergo bowel resection (p = 0.017, 0.009, and 0.015, respectively)., Conclusion: As the aging population continues to expand, the number of patients with obturator hernias is speculated to increase. Elderly people with comorbidities require immediate operative procedures because their general condition tends to be exacerbated by bowel obstruction. Postoperative management may be carefully performed in patients with bowel resection because the postoperative mortality rates may be higher in these patients.

Obturator hernia is rare. It occurs when part of the pelvic contents protrude through the obturator foramen. It is a diagnostic challenge in the emergency department since the signs and symptoms are non-specific. It often occurs in elderly, emaciated and chronically ill women. The clinical picture include intestinal obstruction with abdominal pain, nausea and vomiting. The treatment is only surgical. Delayed diagnosis of this condition usually leads to a high mortality rate. We report the case of an 83-year-old woman with a strangulated obturator hernia. The hernia was discovered early by computed tomography and was treated by emergency laparotomy. We emphasize on the rule of CT scan to establishing a prompt preoperative diagnosis of an obturator hernia, appropriate planning of surgical intervention and thus optimizing the outcome., Competing Interests: The authors declare no competing interests.

Abdominal wall hernias are prevalent in patients undergoing peritoneal dialysis (PD). Obturator hernias, first described by Arnaud de Ronsil in 1724, are an uncommon type of hernia where intra-abdominal contents protrude through the obturator foramen. The following case highlights a rare presentation of bilateral obturator hernias with right femoral and inguinal hernia in an 82-year-old woman post-PD. This patient presented with 5 months of bilateral thigh pain and swelling and was found to only have a right-sided obturator hernia on computer tomography (CT) scan. Intraoperatively, bilateral obturator hernias were found along with right inguinal and femoral hernias, which were all repaired laparoscopically with polypropylene mesh. Postoperatively, the patient developed a self-limiting port site hematoma and resumed PD 1 month post-surgery. Due to the high morbidity and mortality from obturator hernias, prompt diagnosis and treatment are imperative. Compared with open hernia repair, laparoscopic hernia repairs are associated with quicker return to usual activities and less persisting pain and numbness. This case portrays that laparoscopic approach to bilateral obturator hernias can be considered in patients post-PD., (Copyright © 2019 International Society for Peritoneal Dialysis.)