Successful laparoscopic management of an incarcerated obturator hernia
An 85-year-old female with a background of trans-abdominal hysterectomy, hypertension and a previous thyroid lobectomy, presented acutely with a 1-day history of upper abdominal pain radiating down her left leg associated with numerous episodes of emesis. Her bowels had opened three times in the previous 24 h. She was anorexic for the previous 24 h. She reported a similar episode requiring hospitalization 3 weeks before, which was treated non-operatively in another institution.\nOn examination, her vitals were stable. She displayed mild upper abdominal tenderness without signs of peritonism. Bowel sounds were present. Her haematological investigations were unremarkable. A plain film of abdomen was unremarkable. She was treated presumptively as a small bowel obstruction and non-operative measures were employed and the patient proceeded to have a computed tomography (CT) scan of the abdomen and pelvis, which indicated proximal small bowel obstruction secondary to a left obturator hernia (Fig. ). She proceeded to emergent laparoscopy and subsequent mesh repair of left obturator hernia, containing an obstructed loop of small bowel. There was a concomitant femoral hernia that was repaired separately.\nUnder general anaesthetic, the optical technique for access was utilized at the umbilicus with a 5 mm port. Two further working ports, a 5 and 10 mm, were placed in the right lower quadrant and right hypochondrium, under direct vision. Findings included visualization of small bowel dilatation down to small bowel in a left obturator hernia with an incidental left femoral hernia containing omentum (Fig. ). The incarcerated small bowel was reduced using a pair of non-traumatic forceps and deemed viable. The omentum was reduced from the femoral hernia.\nThe obturator hernia was repaired with Proceed™ Ventral patch (Ethicon, Inc., Sommerville, NJ, USA) tacked with AbsorbaTack™ (Covidien, Mansfield, Inc., MA, USA) fixation device. The initial fixation was performed onto Cooper's ligament. This then allowed the mesh to be spread laterally and fixed to the transversalis fascia. The femoral hernia was repaired with 2 × 2/0 Vicryl (Ethicon, Inc., Sommerville, NJ, USA) sutures placed laparoscopically. Port sites were closed in a routine manner. The patient did suffer a post-operative pneumonia but was treated appropriately, made a good recovery and was discharged home well.