This is a retrospective analysis of the clinical treatment of patients with obturator hernia over a 10-year period in a single center. Patient characteristics, operation time, surgical method, length of hospital stay, postoperative complications and mortalities were retrospectively reviewed. The patients’ characteristics in this study were consistent with previous reports that obturator hernia is a scare type of abdominal hernia with the nickname "little old lady's hernia". It is prevalent in the elderly, chronically illed, multiparous and thin women with many comorbidities[10, 13]. Small bowel is the most common content in the hernia sac, and can also be appendix, omentum, ovary, Meckels diverticulum, fallopian tube and even uterus[14, 15].The diagnosis and treatment are usually delayed until laparotomy due to bowel obstruction, necrosis or inperitonitis which always lead to a high mortality[16, 17, 18]. However, the diagnostic capabilities of CT and MRI have become increasingly accurate[19, 20]. In fact, a multidetector CT scan including pelvis has improved the preoperative diagnosis rate to 90% since it was used to detect obturator hernia by Meziane, et al[22, 23].In our study, all the 86 patients had been diagnosed as obturator hernia based on preoperative computed tomography (CT) findings which provided us with great help and modified our preoperative misdiagnosis of inguinal hernia. A typical CT scan was shown in Fig. 1. Typical small bowel herniated into the right obturator canal (Fig. 1A) and dilated small bowel loops above the site of obstruction (Fig. 1B) were shown. Although Howship-Romberg sign is a definite indicator for obturator hernia[24, 25], it was positive only in 11 cases (12.5%) in this study. According to some previous reports, OH is more likely to occur on the right side due to the fact that sigmoid colon locates at the left-side of the pelvis[26, 27]. However, in our retrospective analysis of 86 patients with OH, there was no significant difference in incidence between the left and right sides.
The difference in 30-day mortality between the surgical and non-surgical groups had provided strong evidence that surgery was the best way to treat the disease. Moreover, obturator hernia repair had traditionally been performed with a lower midline incision approach. Recently, the laparoscopic approach has been reported as a minimally invasive technique and inguinal approach with mesh repair has also been introduced as less invasive treatment. However, if the patient’s general condition is poor (presence of intestinal obstruction, intestinal necrosis or perforation, signs of peritonitis and severe comorbidities), immediate release of intestinal obstruction or segmental bowel resection must be performed with a midline incision under general anesthesia. In such cases, primary closure without prosthetic materials can be chosen in case of a high risk of infection. In the emergency surgery group that we studied, laparotomy was performed through a lower midline incision and primary repaired with simple closure and apposition of the peritoneum in all operations. There was no doubt that 24 (40.7%) cases of intestinal necrosis or perforation were accompanied by intestinal resection without insertion of the mesh. However, in the other 35 patients, we did not place the mesh, although there was no definite intestinal necrosis or perforation. This is because the intestinal wall edema and inflammation were observed intraoperative due to the long and critical incarcerated intestinal obstruction, and some patients even showed ischemic changes in part of the intestinal wall and had caused secondary peritonitis, which did not rule out delayed intestinal necrosis or intestinal perforation. In addition, it was found in our study that the duration of operation was longer and more blood loss was noted in emergency group, especially in the operation of intestinal resection, and the patients were elderly with critical comorbidities, thus shortening the operation time was also an important factor to be considered. Through short-term follow-up,although 23 patients who accepted emergency surgery were transferred to ICU, and the recurrence rate at 3 years after the operation was 5.1%(3/59 cases) at 3 years after the emergency surgery, most of patients had good therapeutic results and could still enjoy their super-aged lives after surgery. For the patients in the elective surgery group who received primary repaired with mesh, the recurrence rate at 3 years after the operation was 7.1% (1/14 cases), which may be the result of our small sample size (only 14 cases). For this patient with recurrence, we conducted telephone follow-up, but the patient did not seek medical treatment later. We did not get accurate information about the cause of recurrence, and we speculated that the mesh may have loosened because it was not firmly fixed.