Journal of Surgical Case Reports, 2022, 2, 1–3

https://doi.org/10.1093/jscr/rjac044
Case Report

case report

A case of intestinal obstruction in a 90-year-old patient

at a tertiary hospital in Central Saudi Arabia with a rare
cause: obturator hernia!
Zeinah Sulaihim1 , *, Lina Alsaadon1 , Roaa Saleh Alsuhaibani2 , Hana Alfaleh3 and Ibrahim Albabtain4
1 Collegeof Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Department of General Surgery, King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia
3 Department of Radiology, King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia
4 Department of Surgery, Ministry of the National Guard-Health Affairs, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International

Medical Research Center, Riyadh, Saudi Arabia

*Correspondence address. PO Box: 5844 College of Medicine King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
Tel: 00-966-555772597; E-mail: zeinahghassan@hotmail.com

Abstract
Obturator hernia is a pelvic f loor type of hernia in which abdominal or pelvic contents protrude through the obturator foramen. It is
considered rare in patients with signs and symptoms of intestinal obstruction causing a diagnostic challenge for clinicians. This case
reports a 91-year-old multiparous female who presented with vague lower abdominal pain associated with obstipation and vomiting.
We present a successful laparoscopic repair of obturator hernia in an elderly female.

INTRODUCTION CASE REPORT

Obturator hernia accounts for <1% of all types of hernias, This case is for a 90-year-old female weighing 37.2 kg with
proving its rareness and difficulty in diagnosis [1]. Due a height of 155 cm (BMI = 15.48 kg/m2 ) who is a known
to its late diagnosis and treatment, almost half of the case of HTN with a previous history of open cholecys-
patients (47%) have high morbidity and mortality rates tectomy 30 years ago and femur fracture fixation. She
[2]. It is commonly found in elderly, multiparous female presented to the emergency department with vomiting
patients, with chronic illnesses and a low body mass for an hour associated with diffuse lower abdominal
index (BMI; [3]). This can be explained by women hav- pain, and obstipation for a long nonspecific time. The
ing a broader pelvis and larger obturator canals, which vomit was mainly food content without mucus or blood.
are usually 2–3-cm long and 1-cm wide [2, 3]. Patients The pain was associated with abdominal distention and
usually present with nonspecific symptoms ranging from loss of appetite. On examination, she was vitally stable,
abdominal or groin pain to intestinal obstruction symp- cachectic with a very small and tiny abdomen. The
toms accompanied by nausea and vomiting [4]. Com- abdomen was distended, soft and lax with tenderness
puterized tomography is a highly sensitive diagnostic mainly in the lower abdomen. No signs of peritoneal
method before surgery, where it allows proper abdominal irritation, and no hernia were appreciated. Howship-
and pelvic visualization of the hernia location, therefore, Romberg sign was not assessed upon examination as
it helps surgeons to rely on the images for laparoscopic patient refused completion of examination.
hernia repair rather than laparotomy [5, 6]. The aim of The patient’s lab results revealed leukocytosis of
this study is to present a case of a patient with signs and (12.40 m/mm3 ), and C-reactive protein of (28 mg/l).
symptoms of intestinal mechanical obstruction, which Abdominal X-ray demonstrated distended small bowel
was diagnosed as an obturator hernia proven by com- loops with multiple air fluid levels (Fig. 1). Moreover, CT
puted tomography (CT) and treated by laparoscopic obtu- revealed right sided obturator foramen hernia containing
rator hernia repair in King Abdulaziz Medical city. a segment of distal ileum causing high-grade small bowel

Received: December 9, 2021. Accepted: January 27, 2022

Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2022.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which
permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
2 | Z. Sulaihim et al.

a Vicryl mesh was elected and inserted as a plug into

the obturator opening using a peritoneal flap and fixed
(Fig. 4). Once the fixation was obtained, a ProGrip mesh
was then applied to cover the whole right area (Fig. 5),
which was covered by the peritoneum afterwards. The
abdomen was inspected and the bowel looked healthy.
Lastly, the ports were removed, the incisions were closed,
the skin was clipped and then the dressing was applied.
Postoperatively, the patient was admitted to the inten-
sive care unit for 1 day due to the high risk of surgery
and to be observed carefully by a multidisciplinary team
Figure 1. Supine and erect abdominal radiograph demonstrate including the surgical team. Then, she was shifted in
distended small bowel loops (red arrow) with multiple air f luid levels
(white arrow) suggesting small bowel obstruction. good condition to the surgical ward for 2 days. Dur-
ing her admission, the patient was vitally stable, con-
scious, communicating, not in pain and tolerating oral
liquid diet. Moreover, the dressing was changed daily and
obstruction, which reached up to 4 cm (Fig. 2). The CT
revealed no signs of surgical site infection. On her second
also showed extensive bronchiectasis and consolidation
postoperative day she was able to ambulate, however
with mucus plugging in the lung base.
was not discharged until the next day after she had a
Due to the high-grade small bowel obstruction, the
bowel motion. Two weeks later, she was followed by the
patient was pushed as an emergency case to the oper-
consultant in the outpatient clinic for clip removal. The
ating room. The surgery started and ended as a laparo-
surgery and all health care workers involved in taking
scopic procedure with three small incisions; 12, 11 and
care of the patient proved the success of the treatment
5 mm port sizes located supraumbilically, right and left
plan as the patient was sent home in good health without
midclavicular line relatively. Once the peritoneum was
any complications.
penetrated, and gas insuff lated, diagnostic laparoscopy
was done, and the obturator hernia with bowel content
was visualized (Fig. 3), with a transitional zone at the
hernia site showing a proximal dilatation and distal col- DISCUSSION
lapse of the small bowel. After that, reduction of the The obturator hernia is defined as a rare type of pro-
hernia content was subsequently made with no signs of trusion of abdominal content into the obturator canal,
gangrene or ischemia of the bowel. Then, the small bowel which is bounded by the obturator muscle medially and
was run as a whole to eliminate any other transitional the pectineus muscle laterally [4]. It is commonly found
zones or pathology, which was unremarkable. Therefore, in elderly multiparous women with low BMI and chronic
as there was no contamination, ischemia or perforation, illnesses with obstructive lung diseases being the most

Figure 2. Axial (a–c) and Coronal (d) contrast-enhanced reformatted CT image of the abdomen shows distal ileal loop segment protrudes through the
right obturator foramen with the herniated segment trapped between the right obturator externus and pectineus muscles (blue arrow), there is
proximal upstream dilated small bowel loops (red arrows). In keeping with high-grade small bowel obstruction due to strangulated obturator hernia.
 A case of intestinal obstruction in a 90-year-old patient | 3

A hernia repair can be either with interrupted sutures

or with mesh application. A retrospective analysis of 80
obturator hernia repairs was published in 2013 and found
a 3-year recurrence rate of 22% for patients who have not
had a mesh repair. On the other hand, 0% recurrence rate
was found in the mesh repair group [9]. In this case, a
synthetic ProGrip mesh was inserted and fixed and no
recurrence was identified by the time of writing this case
report.

Figure 3. An intraoperative figure of the obturator hernia transitional

zone revealing the hernial sac and protruded bowel segment. CONCLUSION
Obturator hernia is a challenging diagnosis and an impor-
tant cause of bowel obstruction with high morbidity and
mortality rate [2]. This report aims to remind health care
professionals to include obturator hernia as a differential
diagnosis for any elderly, thin and multiparous female
with signs and symptoms of intestinal obstruction.

CONFLICT OF INTEREST STATEMENT

Figure 4. An intraoperative figure of the Vicryl mesh plug inserted into
the obturator opening. None declared.

FUNDING
None.

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