Small bowel obstruction secondary to strangulated obturator hernia with transected ileal segment: A case report

Abstract

Introduction and importance: Obturator hernia is a rare abdominal wall hernia (<1 % incidence) that occurs through the obturator foramen, often in elderly, emaciated women. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis is the diagnostic modality of choice, with a high accuracy of 78 %-100 %.

Case presentation: An 84-year-old frail woman with COPD presented with generalized abdominal pain, abdominal distention, vomiting, and right thigh pain. CECT revealed a right-sided obturator hernia causing small bowel obstruction. Emergency exploratory laparotomy revealed a right-sided strangulated obturator hernia. Postoperatively, the patient developed septic shock and multiorgan dysfunction syndrome (MODS) and succumbed to death on the 5th postoperative day.

Clinical discussion: Obturator hernia is a rare abdominal hernia with an incidence of 0.07-1 %, an often-overlooked condition, more common in elderly women (around 70-90 years) with risk factors like low BMI, multiparity, and chronic conditions such as COPD. It presents with nonspecific symptoms, including abdominal pain, distension, and vomiting, and is often difficult to diagnose. Early CECT has improved the preoperative diagnosis rate from 43 % to 90 %, thus playing a crucial role in preventing morbidity and mortality. Treatment is surgical, but the mortality rate is high due to delayed diagnosis, bowel strangulation, and underlying preexisting illness.

Conclusion: Obturator hernias are a rare but important cause of small bowel obstruction, especially in elderly, frail, malnourished women without prior abdominal surgeries. Medial thigh pain and mild abdominal distension warrant high suspicion and prompt diagnosis using CECT. Early surgical intervention is critical to prevent severe complications and reduce associated morbidity and mortality.

Keywords: Abdominal pain; Bowel obstruction; Case report; Howship-Romberg sign; Laparotomy; Obturator hernia.

Fig. 1

CECT Axial section- A: Small bowel herniating through the right obturator canal. B: Small bowel loop trapped between obturator externus and pectineus muscle. CECT: Contrast-enhanced computed tomography.

Fig. 2

CECT coronal(A) and sagittal(B) section showing right-sided obturator hernia with small bowel (yellow arrow) herniating through the right obturator canal. CECT: Contrast-enhanced computed tomography. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3

Intraoperative picture showing proximal and distal ileal loop herniating through the right obturator canal. Yellow arrow showing perforated ileum. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 4

Intraoperative picture showing transected ileum after ileal loop release from obturator canal.

Fig. 5

Intraoperative picture showing Obturator foramen.