An obturator hernia is exceedingly rare and the diagnosis is usually made at laparotomy for small bowel obstruction. Several methods of dealing with the hernial defect have been described. Two cases of obturator hernias in nonagenarians are reported and a new, simple and effective method of repairing the hernia by suturing a polypropylene (Prolene) mesh to Cooper’s ligament is proposed.
The hernia was reduced by gentle traction on the bowel. The sac was inverted and excised after ligating the neck with 2-0 Vicryl (Ethicon Ltd, P0 Box 408, Bankhead Avenue, Edinburgh EH11 4HE, UK). The peritoneum over the pecten pubis was incised and elevated to expose the obturator canal, internal obturator fascia and iliac vessels. A 6 x 11 cm polypropylene (Prolene Ethicon Ltd) mesh was sutured to Cooper’s (pectineal) ligament with 2-0 Prolene. Medially, the mesh was sutured to the fascia over the pubis to cover the pubic symphysis (Figure 1). The mesh was left to hang and cover the obturator canal and reperitonealized by suturing the incised peritoneum with 2-0 Vicryl. The repair was completed in 10 minutes.
Obturator hernias are rare and a pre-operative diagnosis is exceptional, the vast majority being diagnosed at laparotomy for small bowel obstruction.1-3 A midline laparotomy is therefore the favoured approach. Excellent views of the obturator canal, nerve and vessels are obtained and a bowel resection, necessitated in up to 80% of cases,2 is easily performed.
There are several ways of repairing the hernial defect, though some prefer leaving it open. The recurrence rate of unclosed defects is not known. Closure of the defect with single or multiple sutures risks damaging the obturator nerve and vessels and some defects are too large to close by simple suture.3
 | Figure 1 Diagrammatic representation of operative repair showing polypropylene mesh sutured to Cooper’s ligament and covering the obturator canal. |
Various methods of mesh repair have been attempted (Table 1), but the present technique is unique in its simplicity and that all sutures are placed away from vital structures, thus minimizing the possibility of injury. Procedures utilizing the uterine fundus, round ligament or bladder distort normal anatomy and the insertion of foreign bodies into the obturator canal could compress the neurovascular structures similar to the hernia. The repair described herein does not appreciably prolong the operation and the incidental reexploration of one patient established its efficacy. Bilateral hernias are easily tackled and this method could be used for laparoscopic obturator hernia repair.
Table 1 Techniques for repair of obturator hernia
| Reference | Technique |
|---|---|
| Short BMJ 1923; 1:718 | Inserted plug of costal cartilage into obturator ring |
| Horine Ann Surg 1927; 86: 776—81 | Inverted apex of sac and sutured sac to perironeum |
| Grey-Turner quoted in Lancet 1938; 1: 721—2 | Inverted sac from within and ligated the base |
| Wakeley BrJSurg 1939; 26: 515—25 | Ligated sac; sutured innermost fibres of pectineus muscle to periosteum of obturator canal |
| Throckmorton Surgery 1950; 27: 888—92 | Sutured tantalum gauze, to periosteum of pubic ramus and to obturator membrane |
| Pender BMJ 1950; 2:1038 | Thigh incision. Plugged obturator canal with rolled up tantalum gauze held in place by suturing adductor brevis over lower end |
| Rothman NYJMed 1951; 51: 1186 | Used a patch of peritoneum to close defect |
| Stone and McLanahan In: Lewis DD, ed. Practice of Surgery. Vol. 7 Hagerstown: Prior, 1954: 68—9 | Elevated an osteoperiosteal flap from pubic bone and rotated it to close defect |
| Harper and Holt AmJSurg 1956; 92: 562—5 | Used a simple purse stringsuture at neck of sac |
| Gilfillan Can JSurg 1958; 1: 366—7 | Everted and ligated sac. Filled defect with plug of free omentum |
| Rogers Surgery 1960; 48: 394~403 | Sutured patch of Teflon around defect |
| Hanley and Hanna IrMed 11970; 63: 396—8 | Used uterine fundus to obliterate defect |
| Larrieu and DeMarco Am Surg 1976; 42: 273—7 | Sutured Marlex mesh around defect. Uterus and round ligament used to reinforce mesh |
| Aurousseau et at. J Chir 1978; 115: 35—8 | Used round ligament to obliterate defect |
| Arbman Acta C/sir Scand 1984; 150: 3 37—9 | Sutured wall of urinary bladder to pelvic wall and round ligament to obliterate defect |
| Bjork Surg Gynecol Obstet 1988; 167: 217—22 | Used locally available obturator fascia to repair defect |
| Carriquiry and Pineyro Bri Surg 1988; 75: 785 | Placed a polypropylene mesh beneath pubis, covering both obturator foramina |
| Tchupetlowsky etal. Surgery 1995; 117: 109—12 | Inserted cylinder of Ampoxen mesh into obturator canal. Mesh secured with Policon sutures |
| Bergstein and Condon Surgery 1996; 119:133—6 | Both obturator foramina covered with preperitoneal Marlex mesh. Mesh sutured to endoabdominal and endopelvic fascia |
The peritoneal dissection must extend to expose the iliac vessels to enable insertion of the entire mesh and prevent rolling of its free lower border. It is important not to trim the mesh because a greater surface area minimizes the possibility of displacement before the interstices are infiltrated by fibroblasts. Medial fixation of the mesh to the pubic tuberele and fascia over the symphysis is recommended. These precautions are also said to reduce the recurrence rate of laparoscopic inguinal hernia repairs.4
Polypropylene is an ideal mesh material because it is inert, strong, thin and non-absorbable. It lacks intrinsic antibacterial activity, but is capable of withstanding infection.5 Outpatients have shown that with antibiotic prophylaxis it is safe to use polypropylene mesh and perform a small bowel resection, but we would not recommend it in the presence of peritonitis.
In conclusion, this method of obturator hernioplasty is simple, safe, effective and easily reproducible. The rapidity with which the repair is performed makes it particularly suitable in elderly patients in whom it is vital to minimize operating time.
- Bjork KJ, Mucha P, Cahill DR. Obturator hernia. Surg Gynecol Obstet
- 1988; 167: 217—22.
- Lo CY, Lorentz TG, Law PWK. Obturator hernia presenting as small bowel obstruction. AmJSurg 1994; 167: 396—8.
- Rogers FA. Strangulated obturator hernia. Surgery 1960; 48: 394—403.
- Brough W, Royston C. TAPP repair: the Hull and Stockport experience. In: Darzi A, Monson JRT, eds. Loparoscopic Inguinal Hernia Repair. Oxford: Isis Medical Media, 1994: 48—61.
- Walker AP. Biomaterials in hernia repair. In: Nyhus LM, Condon RE, eds. Hernia. Philadelphia: Lippincott, 1995: 534—40.
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