Obturator hernia combined with femoral hernia: A case report

Abstract

BACKGROUND

Obturator hernia is an abdominal wall hernia in which intra-abdominal contents protrude through the obturator foramen of the pelvis into the femoral triangle region, which is bounded by the inguinal ligament, medial border of the adductor longus muscle, and medial border of the sartorius muscle. Femoral hernia occurs when a hernia sac passes through the femoral ring and descends along the femoral canal, emerging at the saphenous opening (fossa ovalis). Obturator hernia is uncommon in clinical practice, and obturator and femoral hernias occur more frequently in women. We present a rare case of concurrent obturator and femoral hernias, and review relevant literature to provide insights for selecting appropriate diagnostic and therapeutic strategies.

CASE SUMMARY

An 84-year-old female patient presented to our hospital with pain in the right groin area for more than one week, which had worsened in the past day. Physical examination revealed a soft, tender mass approximately 3 cm × 2 cm below the right inguinal ligament. Laboratory findings were unremarkable. Abdominal computed tomography performed at a local health center suggested a right obturator hernia, while abdominal color Doppler ultrasound performed at our hospital indicated a cystic mass adjacent to the right obturator externus muscle. Based on the symptoms, signs, and imaging findings, the initial diagnosis was right obturator hernia. However, intraoperative exploration confirmed the condition as a right obturator hernia combined with a femoral hernia.

CONCLUSION

Obturator hernia combined with femoral hernia is rare and has a high risk of incarceration, necessitating urgent surgery.

Key Words: Obturator hernia; Femoral hernia; Incarceration; Surgical treatment; Case report

Core Tip: We report a rare case of obturator hernia combined with femoral hernia. We reviewed the relevant literature, compared the predisposed population, and described initial symptoms, imaging findings, final diagnosis, and surgical management of obturator hernia complicated with femoral hernia, in order to provide a reference for subsequent clinical practice.

INTRODUCTION

Obturator hernia is a rare type of abdominal hernia, in which abdominal contents protrude through the obturator canal[1]. The incidence of obturator hernia accounts for approximately 0.73% of all hernias[2]. Typical patients are elderly, parous women with chronic diseases and emaciation, which is known as hernia of emaciated elderly women[3]. Femoral hernia refers to a protrusion of the peritoneal sac into the medial aspect of the femoral canal through the femoral ring[4]. Femoral hernia is also rare, accounting for 2%-8% of all inguinal hernias. It most commonly occurs in middle-aged and elderly women, and approximately 70% of femoral hernias progress to incarcerated hernias[5,6]. The incidence of isolated obturator hernia or femoral hernia is low. We here report a case of an 84-year-old female patient with concurrent obturator hernia and femoral hernia, which is extremely rare.

CASE PRESENTATION

Chief complaints

An 84-year-old female patient was admitted to our hospital for treatment due to pain in the right inguinal region for more than one week, which had aggravated in the past day.

History of present illness

The patient developed paroxysmal pain in the right inguinal region for more than one week, which was mild and tolerable; no other discomfort was noted, and no treatment was administered. One day ago, the patient reported aggravated persistent pain in the same region. Abdominal computed tomography (CT) performed at a local hospital suggested right obturator hernia, and the patient was referred to our hospital for further management.

History of past illness

After a detailed medical history inquiry, it was found that the patient had hypertension without any medication, and her blood pressure control was poor. The patient had previously undergone right inguinal hernia repair and splenectomy.

Personal and family history

The patient denied any family history of cancer.

Physical examination

The patient was conscious, sclerae were nonicteric, and superficial lymph nodes were not enlarged. Abdominal examination revealed a flat, soft abdomen with no significant or rebound tenderness throughout, and normal bowel sounds. A 3 cm × 2 cm mass was palpable below the right inguinal ligament, which was soft in texture and tender to palpation.

Laboratory examinations

Complete blood count showed decreased white blood cell count (3.41 × 10⁹/L), neutrophil percentage of 39.70%, and normal high-sensitivity C-reactive protein level (1.09 mg/L). The red blood cell count was normal (3.99 × 10¹²/L), and platelet count was also within the normal range (142 × 10⁹/L). High-sensitivity troponin I (0.031 ng/L) and brain natriuretic peptide (44.85 pg/mL) were normal. The bronchodilation test was negative, indicating normal cardiopulmonary function. Prothrombin time and activated partial thromboplastin time were normal, while D-dimer level was elevated (740 μg/L). Tumor markers and thyroid function were all within the normal range.

Imaging examinations

Abdominal CT performed at a local hospital revealed a round-like hypodense shadow lateral to the right obturator foramen, with punctate hyperdense foci visible inside (Figure 1A). To confirm the diagnosis, abdominal color Doppler ultrasound was conducted at our hospital, which indicated a cystic mass measuring 65 mm × 52 mm adjacent to the right obturator externus muscle. The mass had a clear boundary, thin wall, and good internal acoustic transmission (Figure 1B).

Figure 1 Preoperative imaging findings. A: Computed tomography shows a round-like hypodense shadow outside the right obturator foramen, with punctate dense shadows inside; B: Abdominal color Doppler ultrasound shows a 65 mm × 52 mm cystic mass detected beside the right obturator externus muscle.

FINAL DIAGNOSIS

Based on the patient’s aforementioned symptoms, physical examination findings, and imaging data, a preliminary diagnosis of right obturator hernia was made. Final diagnosis of concurrent right obturator hernia and femoral hernia was confirmed intraoperatively.

TREATMENT

Given the high risk of incarceration of obturator hernia, surgical treatment was selected. A midline infraumbilical incision approximately 10 cm in length was made; the skin and subcutaneous tissue were incised down to the preperitoneal space, which was then dissected. Subsequently, the right vesicopubic space was separated, and exploration to the right obturator foramen revealed a hernial sac structure containing extraperitoneal fat. Enlargement of the right femoral ring was noted, with a hernial sac and extraperitoneal fat extending to the subcutaneous tissue lateral to the inguinal ligament (Figure 2A).

Figure 2 Intraoperative images. A: Obturator foramen (white arrow), femoral canal (blue arrow); B: A hernia repair mesh was placed in the preperitoneal space.

OUTCOME AND FOLLOW-UP

The tissues surrounding the hernial sacs were dissected, and the femoral and obturator hernial sacs, along with the extraperitoneal fat, were reduced. The preperitoneal space was further dissected on the right side to the level of the anterior superior iliac spine superiorly, 3 cm posterior to the pubis inferiorly, and the level of the pubic symphysis medially. A preperitoneal hernia repair mesh (16 cm × 8.5 cm) was placed to cover the myopectineal orifice and obturator foramen; the mesh was fully flattened and secured with two stitches using Vicryl sutures (Figure 2B). Finally, after rechecking the surgical field for no active bleeding and confirming that the counts of gauze and surgical instruments were correct, the abdomen was closed. The patient had an uneventful postoperative recovery with no complications. Abdominal CT was repeated on postoperative day 3 (Figure 3), and the patient was discharged 6 days after admission. The patient returned for a follow-up visit two weeks after surgery, and her recovery was satisfactory.

Figure 3 Abdominal computed tomography images of postoperative re-examination. Imaging manifestations after repair of right obturator hernia combined with femoral hernia.

DISCUSSION

An abdominal external hernia refers to a condition in which abdominal organs or tissues deviate from their normal anatomical position and protrude outside the skin through congenital or acquired weaknesses, abdominal wall defects, or foramina, and include inguinal, umbilical, and femoral hernia. Constipation, persistent cough, history of abdominal surgery, and heavy lifting are significantly associated with abdominal external hernias[7].

Obturator hernia is an abdominal external hernia, which is considered to be caused by progressive relaxation of the pelvic floor; possibly related to advanced age, emaciation, increased intra-abdominal pressure, and multiparity[1]. Obturator hernia tends to occur in elderly emaciated women, as compared with men, women have a tilted pelvis, a larger transverse diameter, and a higher degree of pelvic floor relaxation[8]. Obturator hernia is more common on the right side, due to the support of the sigmoid colon on the left side[9]. Femoral hernia is also an abdominal external hernia, and its risk factors include female gender, pregnancy, obesity, and diseases that increase intra-abdominal pressure[10]. Femoral hernia also tends to occur in middle-aged and elderly women, and is more common on the right side than the left, but the reason for this is unclear. In this case, we report an 84-year-old woman with a body mass index of 16.89 kg/m² (emaciated), who underwent right inguinal hernia repair several years ago, and was finally diagnosed with concurrent obturator hernia and femoral hernia.

Early diagnosis of obturator hernia is difficult, as it usually presents with nonspecific signs and symptoms. The main clinical symptoms are caused by intestinal obstruction, such as abdominal pain, abdominal distension, nausea, vomiting, and constipation. Relatively specific signs caused by obturator nerve compression include the Howship-Romberg and Hannington-Kiff signs. The Howship-Romberg sign is defined as radiating pain in the medial aspect of the lower extremity, while the Hannington-Kiff sign refers to the absence of the adductor reflex of the thigh. Some studies have reported that the Howship-Romberg sign can be observed in 37%-60% of cases[2,11]. In this case, the patient only presented with pain in the right inguinal region, without obvious symptoms of intestinal obstruction.

Ultrasonography is considered a rapid, noninvasive, inexpensive, and easily accessible diagnostic tool for hernias, but it depends on the technician's skills and experience. Sometimes, the examiner may miss the diagnosis due to failure to scan the target area, or fail to identify the hernia[12]. For patients with suspected obturator hernia who do not require emergency laparotomy, urgent CT scanning may lead to rapid diagnosis and early surgical intervention. As diagnosis is often delayed until complete intestinal obstruction or peritonitis becomes evident, this delay results in high morbidity and mortality associated with the disease[13]. The use of CT scanning to detect obturator hernia was first reported in 1983. Since the application of CT scanning, the reported preoperative diagnostic rate has increased from 43% to 90%[2]. In the present case, abdominal CT performed at a local hospital suggested right obturator hernia, and abdominal color Doppler ultrasound at our hospital indicated a cystic mass adjacent to the right obturator externus muscle. Based on the aforementioned symptoms, signs, and imaging evidence, we made a preliminary diagnosis of right obturator hernia.

Surgical treatment is standard for obturator hernia; mainly including open surgery and laparoscopic surgery. Open surgery via a lower midline incision is the most common surgical method for emergency cases, as it provides optimal exposure. However, with the continuous development of medical technology, laparoscopic treatment of obturator hernia has been gradually accepted by surgeons, with advantages such as reduced postoperative pain and shorter hospital stay. Hernia repair can involve simply closing the hernia orifice with interrupted sutures, or mesh repair. A retrospective analysis of 80 patients from the same institution, published in 2014, compared mesh repair and non-mesh repair for obturator hernia, and concluded that mesh repair is more beneficial for preventing the recurrence of obturator hernia; therefore, a mesh should be placed if there are no obvious contraindications[14,15]. In this case, we performed open surgery and placed a preperitoneal hernia repair mesh. During the operation, we found an obturator hernia, with extraperitoneal fat inside. Three stages of obturator herniation have been described. The first stage is signified by the entrance of preperitoneal tissue (fat) into the obturator canal; the second stage involves the development of a dimple in the peritoneum overlying the canal; and the third stage is the entrance of an organ into the canal accompanied by the onset of symptoms[13]. The patient was in the first anatomical stage of obturator hernia formation, which explained the absence of obvious intestinal obstruction symptoms. Additionally, we identified a concurrent femoral hernia in the patient, which also accounted for the presence of a 3 cm × 2 cm mass below the right inguinal ligament. The coexistence of obturator and femoral hernias is extremely rare in clinical practice.

We conducted a literature search and review of the PubMed and Web of Science databases, excluded articles with incomplete data, and obtained 15 articles on obturator hernia combined with femoral hernia (Table 1)[11,14,16-28]. Most articles showed that obturator hernia combined with femoral hernia mostly occurs in elderly women, and is mainly characterized by symptoms such as abdominal pain, nausea and vomiting. It is not easy to detect the coexistence of these two hernias by imaging, and the diagnosis is confirmed during surgery. Therefore, elderly emaciated women with inguinal pain should be alert to the presence of obturator hernia alone or combined with femoral hernia. If obturator hernia is suspected clinically, surgical intervention should be performed in a timely manner. Delayed treatment may lead to life-threatening conditions. Imaging examinations such as CT can greatly improve the diagnostic rate. Clinicians should consider the existence of such conditions in clinical practice.

Table 1 Literature review on obturator hernia combined with femoral hernia.

Ref.	Sex	Age, year	Symptoms	Imaging findings	Final diagnosis	Surgical approach
Watkins et al[16]	Female	43	Obstruction and tenderness of the left inguinal region	Upright abdominal X-ray showed dilated small bowel loops with air-fluid levels	Left femoral hernia combined with left obturator hernia	Open surgery
Uludag et al[17]	Female	77	Nausea, vomiting, abdominal pain, as well as swelling and pain in the right inguinal region	Findings of upright abdominal X-ray: Multiple dilated loops of small intestine with air-fluid levels	Right femoral hernia complicated with left obturator hernia	Open surgery
Lynch et al[18]	Female	85	Abdominal pain	Finding on CT: Left obturator hernia complicated with small bowel obstruction	Left obturator hernia combined with left femoral hernia	Laparoscopic surgery
Seppälä et al[19]	Female	91	Vomiting	Finding on CT: Suspected right inguinal hernia	Right obturator hernia combined with right femoral hernia	Open surgery
Santorelli et al[14]	Female	36	Abdominal pain, swelling of the right inguinal region, and signs of intestinal obstruction	Finding on CT: Suspected right inguinal hernia	Right obturator hernia combined with right femoral hernia	Open surgery plus laparoscopic surgery
Malik et al[20]	Female	75	Specific bilateral inguinal pain radiating to the thighs	Finding on CT: Bilateral obturator hernia	Bilateral obturator hernia combined with bilateral femoral hernia	Laparoscopic surgery
Jiang et al[11]	Female	83	Abdominal pain, abdominal distension, vomiting, flatulence and absence of defecation	Finding on CT: Suspected left inguinal hernia, right femoral hernia, and right obturator hernia	Left inguinal hernia combined with right femoral hernia and right obturator hernia	Open surgery
Ramkumar et al[21]	Female	82	Bilateral thigh pain and swelling	Finding on CT: Right obturator hernia	Bilateral obturator hernia combined with right inguinal hernia and right femoral hernia	Laparoscopic surgery
Polyakov et al[22]	Unknown	80	Persistent abdominal pain and irreducible mass in the right inguinal region	Finding of upright abdominal plain film: Signs of intestinal obstruction	Left recurrent indirect hernia; right combined hernia (femoral hernia, obturator hernia, indirect hernia and direct hernia)	Laparoscopic surgery
Nguyen and Nguyen[23]	Female	81	Acute onset of medial thigh pain and intestinal obstruction	Finding on CT: Obturator hernia	Right obturator hernia combined with right femoral hernia	Laparoscopic surgery
Chiba et al[24]	Female	86	Lower abdominal pain and vomiting	Finding on CT: Right obturator hernia	Bilateral obturator hernia complicated with bilateral femoral hernia	Laparoscopic surgery
Fujita et al[25]	Female	68	Abdominal pain	Finding on CT: Concurrent left inguinal hernia, Nuck’s canal hydrocele, or left femoral hernia	Left inguinal hernia complicated with left femoral hernia and left obturator hernia	Laparoscopic surgery
Naito et al[26]	Female	70	Abdominal pain accompanied by vomiting	Finding on CT: Right femoral hernia and right obturator hernia involving the bladder	Right femoral hernia complicated with right obturator hernia	Laparoscopic surgery
Neureiter et al[27]	Female	79	Right lumbar pain	Finding on CT: Right obturator hernia	Right obturator hernia complicated with right femoral hernia	Laparoscopic surgery
Zhu et al[28]	Female	80	Progressive pain from the medial left thigh to the knee, accompanied by limited mobility of the left limb	Finding on CT: Left incarcerated obturator hernia	Left incarcerated obturator hernia complicated with left inguinal hernia and femoral hernia; right obturator hernia complicated with right femoral hernia	Laparoscopic surgery
Present case	Female	84	Right inguinal pain	Finding on CT: Right obturator foramen	Right obturator hernia complicated with right femoral hernia	Open surgery

CT: Computed tomography.

CONCLUSION

The combination of obturator hernia and femoral hernia is extremely rare in clinical settings. Once diagnosed or highly suspected, prompt surgical intervention is imperative.