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PURPOSE: Obturator Hernia (OH) is a rare type of abdominal wall hernia. It usually occurs in elderly women with late symptomatic presentation, increasing mortality rates. Surgery is the standard of care for OH, and laparotomy with simple suture closure of the defect is commonly used. Given the rarity of this disease, large studies are lacking, and data to drive management are still limited. This systematic review and meta-analysis aimed to describe current surgical options for OHs, with a focus on comparing the effectiveness and safety of mesh use with primary repair. METHODS: PubMed, EMBASE, and Cochrane were searched for studies comparing mesh and non-mesh repair for OH. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. RESULTS: One thousand seven hundred and sixty studies were screened and sixty-seven were thoroughly reviewed. We included 13 observational studies with 351 patients surgically treated for OH with mesh or non-mesh repair. One hundred and twenty (34.2%) patients underwent mesh repair and two hundred and thirty-one (65.81%) underwent non-mesh repair. A total of 145 (41.3%) underwent bowel resection, with the majority having a non-mesh repair performed. Hernia recurrence was significantly higher in patients who underwent hernia repair without mesh (RR 0.31; 95% CI 0.11-0.94; p = 0.04). There were no differences in mortality (RR 0.64; 95% CI 0.25-1.62; p = 0.34; I2 = 0%) or complication rates (RR 0.59; 95% CI 0.28-1.25; p = 0.17; I2 = 50%) between both groups. CONCLUSION: Mesh repair in OH was associated with lower recurrence rates without an increase in postoperative complications. While mesh in clean cases is more likely to offer benefits, an overall recommendation regarding its use in OH repair cannot be made due to potential bias across studies. Given that many OH patients are frail and present emergently, the decision to use mesh is complex and should consider the patient's clinical status, comorbidities, and degree of intraoperative contamination.

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Introducción. Debido a la rareza de la hernia obturatriz y la imposibilidad para desarrollar estudios controlados de alto grado de evidencia, la mayoría de la literatura al respecto proviene de reportes de casos. Lo anterior, aunado al poco conocimiento del área anatómica de presentación y el cuadro clínico, la convierte en la hernia con mayor mortalidad. Métodos. Se realizó una búsqueda de la literatura en las principales bases de datos, ilustrado con pacientes manejados en el Servicio de Cirugía general de la Clínica Santa María de Sincelejo, Colombia. Discusión. La hernia obturatriz se puede descubrir en mujeres ancianas con antecedentes de cirugía abdominal o multiparidad. El signo de Howship­Romberg, que se presenta en la mitad de los pacientes, puede acompañarse de dolor abdominal en hipogastrio, vómitos y distensión progresiva. La radiografía de abdomen simple muestra tardíamente niveles hidroaéreos con ausencia de gas en ampolla rectal, pero como es poco específica para demostrar el sitio de obstrucción, es preferible la Tomografía computarizada. Conclusión. La hernia obturatriz requiere alto índice de sospecha, que ayude a la detección temprana e intervención quirúrgica inmediata, para evitar las complicaciones.

Introduction. Due to the rarity of the obturator hernia and the impossibility to develop controlled studies with a high degree of evidence, most of the reference in the literature comes from case reports. This, coupled with little knowledge of the anatomical area of presentation and clinical picture, makes it the hernia with the highest mortality. Methods. A literature search was carried out in the main databases, illustrated with patients managed in the General Surgery Service of the Clínica Santa María de Sincelejo. Discussion. Obturator hernia can be discovered in elderly women with a history of abdominal surgery or multiparity. The Howship ­ Romberg sign occurs in half of the patients, it can be associated with lower abdominal pain, vomiting, and progressive distension. Plain abdominal X-ray shows delayed air-fluid levels with absence of gas in the rectal ampulla, but since it is not very specific to demonstrate the site of obstruction, computed axial tomography is preferable. Conclusion. Obturator hernia requires a high index of suspicion, which helps early detection and immediate surgical intervention, to avoid complications.

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OBJETIVO: Se presentan 3 casos de obstrucción intestinal por hernia obturatriz atascada, su manejo y una breve revisión de la literatura. MATERIALES Y MÉTODOSles y Métodos: Discusión del cuadro clínico, imágenes y manejo. Todos los casos fueron operados dentro del mismo día del diagnóstico y se confirmó la presencia de hernia obturatriz. El manejo de la hernia y su contenido fue ajustado a la situación de cada paciente. RESULTADOS: Los tres casos de hernia obturatriz aquí discutidos tienen la presentación clásica del cuadro, cuando se los revisa en forma retrospectiva y con imagenología compatible. Los tres pacientes evolucionaron en forma satisfactoria con alta precoz y control posoperatorio sin incidentes. Discusión: Nuestros 3 casos se condicen tanto en hallazgos clínicos, imagenológicos y en manejo con lo descrito en la literatura internacional. CONCLUSIÓN: La hernia del agujero obturatriz siendo infrecuente, se presenta en un tipo particular de pacientes y con sintomatología clásica. La tomografía axial computada es de gran ayuda y suele hacer el diagnóstico preciso en el preoperatorio. Es importante recordar este diagnóstico diferencial al momento de estudiar pacientes con obstrucción intestinal.

OBJECTIVE: 3 cases of intestinal obstruction that resulted in diagnosis of obturator hernia, their management and a brief international literature review are presented. MATERIAL AND METHODS: Discussion of the presentation, images, and management. In all cases surgery was performed the same day from the diagnosis of intestinal obstruction and confirmation of obturator hernia. The management of the hernia and it's content was adjusted to each patient's situation. RESULTS: Our 3 patients, when reviewed retrospectively, had the classic presentations and images of obturator hernia. All of them had a favourable evolution with an early discharge and no complications on follow up. DISCUSSION: Our 3 cases had clinical presentations and imaging studies that correlated well with international literature. CONCLUSION: Obturator hernia is an infrequent pathology, but appears in a particular type of patient and with classic presentation. Axial computed tomography is an important tool and usually makes the diagnosis previously to surgical exploration. It is important to consider this diagnosis when being faced with patients with intestinal obstruction.

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La hernia obturatriz tiene una baja incidencia, predomina en mujeres ancianas desnutridas, habitualmente con signos y síntomas poco específicos, situación que requiere resolución quirúrgica precoz para disminuir la morbi-mortalidad. Materiales y métodos: Análisis retrospectivo observacional sobre tres casos de oclusión intestinal por hernia obturatriz en el servicio de Cirugía General del Hospital Italiano de Córdoba entre el período comprendido desde enero de 2013 a diciembre de 2015. Resultados: Los tres pacientes fueron diagnosticados por TC en el preoperatorio, en dos se debió realizar resección intestinal y entero-entero anastomosis. Conclusión: la cirugía de urgencia es el tratamiento ideal

Obturator hernia is a rare type of hernia. Because of its low incidence, predominantly in elderly malnourished women, usually with non- specific signs and symptoms, diagnosis and treatment are often delayed. This situation requires early surgical treatment to prevent serious morbidity and mortality associated with this entity. Methods: Retrospective observational analysis of 3 cases of intestinal occlusion due to complicated obturator hernia at the Department of General Surgery, Hospital Italiano Córdoba, Argentina, between January 2013 to December 2015. Results: All three cases were diagnosed preoperatively by CT , but in two of the three cases it was due to perform an intestinal resection with anastomosis. Conclusion: The surgery performed early after admission, is the treatment of choice.

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Si bien el diagnóstico de hernias de la pared abdominal es clínico y el estudio más indicado es la ecografía, en una gran cantidad de casos es difícil su evaluación o no se sospecha su presencia debido al biotipo del paciente, la ausencia de síntomas, la aparición de complicaciones o corresponde a algún tipo de hernia poco frecuente. Además, la debilidad de la pared abdominal generada por una cirugía predispone a la eventración de órganos, a veces poco habituales, como el hígado, la vejiga o el apéndice. La utilización de la tomografía computada multidetector (TCMD) brinda grandes ventajas cuando resulta dificultoso establecer el diagnóstico por otros métodos. También puede ser un hallazgo incidental a tener en cuenta por sus posibles complicaciones futuras. En el presente trabajo describimos los principales hallazgos por TCMD de las hernias y eventraciones de la pared abdominal (como la umbilical, epigástrica, hipogástrica, inguinal, de Spiegel, lumbar, obturatriz, intercostal e incisional) y su contenido.

Although the diagnosis of abdominal wall hernias is clinical, and the most appropriate study is ultrasound, in a lot of cases they are difficult to evaluate, or their presence is not suspected because of the biotype of the patient, the absence of symptoms, the presence of complications, or the appearance of rare hernias. Surgery weakness generated in the wall leads to organ hernia, sometimes unusual, as in the liver, bladder, or appendix. The use of multidetector computed tomography (MDCT) is a great advantage in these situations where the diagnosis can be difficult to determine with other methods. It also can be an incidental finding to consider eventual complications. In this paper, the main MDCT findings in abdominal wall hernias are described, including umbilical, epigastric, hypogastric, inguinal, Spiegel, lumbar, obturator, intercostal, and incisional, as well as their content.

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BACKGROUND: Obturator hernia is a rare variety of abdominal hernia, it accounts for 0.07%-1.0% of all hernias, and occurs most often in women of advanced age and multiparous. CLINICAL CASE: A 78-year-old female was admitted to the Emergency Department due to nausea, vomiting, complaints of abdominal discomfort and obstipation for the last 7 days. Abdominal CT scan showed dilated small bowel loops and multiple air-fluid levels near to a small bowel loop obturator hernia, between external obturator and pectineus muscle. Emergency laparotomy was performed and during the surgery, loop of small intestine was revealed herniated into the obturator foramen, 130cm from the angle of Treitz. Necrosis of small intestine was found, without perforation. Resection of the 10cm affected jejunal segment was performed and a side-to-side bowel anastomosis was fashioned. Also simple suture closure of obturator foramen was performed. CONCLUSION: Obturator hernia is relatively rare. However physicians should keep it in mind and have clinical suspicion for obturator hernia as a cause of intestinal obstruction in female, elderly and multiparous patients in order to make an appropriate diagnosis and avoid bowel ischaemia.

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La hernia obturatriz (HO) es poco frecuente y representa del 0.05 al 0.4 por ciento del total de hernias. Debido a su rareza y a su presentación inespecífica, el diagnóstico es por lo general tardío y las tasas de mortalidad elevadas (12-70 por ciento). Se presenta un caso típico de HO diagnosticada en el preoperatorio mediante TC Multi-corte con RMP y tratado mediante laparotomía de urgencia con buen resultado. El empleo de TC Multicorte con RMP de abdomen y pelvis, en cuadros de obstrucción intestinal en mujeres añosas, sin antecedente de cirugías previas ni hernias objetivables, tiene gran valor para el diagnóstico preoperatorio precoz de HO y podría contribuir a reducir las elevadas tasas de morbilidad y mortalidad.

Abstract. The obturator hernia (OH) is rare and accounts for 0.05 to 0.4% of all hernias. Because of its rarity and its nonspecific presentation, diagnosis is usually late and has high mortality rates (12-70%). A typical case of OH diagnosed preoperatively by Multislice CT with MPR and treated using emergency laparotomy with good results, is presented. The use of Multislice CT with MPR of the abdomen and pelvis, in symptoms of intestinal obstruction in elderly women with no history of previous surgery or objectified hernias, has great value for early preoperative diagnosis of OH and could help reduce the high rates of morbidity and mortality.

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Objetivos: descrever a história, o diagnóstico e o tratamento de uma paciente com hérnia obturadora.Descrição do caso: uma paciente de 71 anos apresentou quadro de abdome agudo obstrutivo secundário a uma hérnia obturadora encarcerada e recidivada. O diagnóstico foi feito pela tomografia computadorizada e o tratamento foi cirúrgico, através da correção do defeito com colocação de tela de polipropileno em forma de cone.Conclusões: a hérnia obturadora é uma rara mas importante causa de obstrução intestinal. Por ser uma patologia incomum, seu diagnóstico normalmente é tardio, sendo realizado no transoperatório ou, menos frequentemente, através de tomografia computadorizada em avaliação pré-operatória de abdome agudo. Existem diversas formas para sua correção cirúrgica.

Aims: To describe the history, diagnosis and treatment of a patient with obturator hernia.Case description: A 72 years old woman presented with acute obstructive abdomen secondary to an incarcerated recurrent obturator hernia. The diagnosis was made by computed tomography and the treatment was surgical, by repairing the defect with placement of a polypropylene mesh in a cone shape (patch/plug).Conclusions: Obturator hernia is a rare, but important cause of intestinal obstruction. Because it is an uncommon patology, the diagnoses is usually delayed and is done during surgery or, less frequently, by computed tomography in the preoperative evaluation of acute abdomen. There are several strategies for its surgical correction.

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