To make a diagnosis we need to know it and to remember it. We cannot diagnose what we do not know. Sometimes it would be easy to diagnose what was causing symptoms if we had the correct knowledge.
A 91yo female patient was admitted in an emergency department in Greece with colic abdominal pain and obstipation. Additionally she complained of pain in the anteromedial aspect of the right thigh relieving with thigh flexion. On physical examination mild abdominal tenderness was present, with no inguinal or femoral hernias. From the paper published by Garoufalia et al from the Second Department of Propaedeutic Surgery in Athens, we cannot know which diagnosis were suspected by the attending doctor. In my opinion, the most interesting and important symptom is the pain in the thigh, relieving with flexion. It would be crucial to know if there was any kind of swelling/mass in that area. The authors say nothing about that.
A CT scan made the diagnosis: an obturator hernia with incarcerated small bowel. Laparotomy with segmental small bowel resection due to necrosis and mesh repair of the hernia was performed. Six days after, patient was discharged home. A rarity but… did the authors put this diagnosis on the table before CT scan? Would you remember it?
In fact, obturator hernias represent about 0,073% of all hernias. It is one of the three types of pelvic hernias (sciatic, perineal and obturator), and is the most frequent of those. They are found in elderly women in the majority of cases, with the right side affected in 60%. Some authors state that obturator hernias are underdiagnosed in women with chronic pelvic pain. Obturator hernia can be the cause of bowel obstruction, and is usually diagnosed only after incarceration occurs.
There are four main characteristics of this rare hernia:
Howship-Romberg sign (50% of cases) refers to pain in the inner aspect of the thigh – pathognomonic but usually misdiagnosed as arthritis
Bowel obstruction (80% of cases)
Past episodes of bowel obstruction spontaneously solved (30% of cases)
Palpable mass in the medial aspect of the thigh
This condition first described by Arnaud De Ronsil in 1724 is difficult to diagnose. Doctors must know its existence and remember it in front of a case like the one presented. Bowel obstruction with pain in the inner aspect of the thigh in an elderly woman should have raise suspicion. CT scan is crucial to make diagnosis, not forgetting pelvic images must be paid special attention.
Preoperative diagnosis of obturator hernia is a rarity.
Didn’t you think on this diagnosis? You are not the only one. Preoperative diagnosis of obturator hernia is a rarity, occurring only in 10% of cases. This is the reason why midline laparotomy is the most used approach since patients are usually operated for bowel obstruction of unknown etiology. When preoperative diagnosis has been made, extraperitoneal approach is the best method to deal with obturator hernia. Laparoscopic extraperitoneal repair with prosthetic mesh is also available, allowing a wide view of miopectineal orifice and obturator canal.
Always remember that you can only diagnose and treat what you know. Such as the ignorance of the law does not justify the crime, not having seen a particular disease does not justify ignorance. Books describe almost everything, and nowadays videos in scientific websites are of major help for learning. Read, study and be updated.
Link to Article:
Other reference:
Cartes J. Sciatic, obturator, and perineal hernias: A view from the gynecologist. In: Fitzgibbons RJ Jr, Greenburg AG. Nyhus & Condon’s Hernia. Fifth edition. Lippincott Williams & Wilkins; 2002. 542-546.
by Dr. Carlos Eduardo Costa Almeida
General Surgeon