4rd Annual Resident Hernia Case Presentation Competition
Case No. 1: Surgical technique: Laparoscopic Repair of Strangulated Obturator Hernia
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AUTHORS: Simran Parmar PGY5, University of Calgary; Nam Hoan Nguyen, University of British Columbia
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CASE PRESENTATION:
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This 85-year-old woman presented from a care home with an incarcerated obturator hernia, concerning for strangulation.
She presented with 5 hours of acute abdominal and left medial thigh pain associated with vomiting and obstipation. On exam she was afebrile, sBP 90, HR 100. She appeared frail. Her abdomen was soft but distended, and not peritonitic. She had tenderness to the left lower quadrant. WBC 11.5, Creatinine normal, Albumin 30. CT abdomen pelvis demonstrated distended small bowel with a transition point in the obturator foramen and associated free fluid. A diagnosis of incarcerated obturator hernia, concerning for strangulation, was made.
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The patient was taken emergently to the operating theater. A nasogastric tube was inserted and the patient underwent awake intubation. A diagnostic laparoscopy was performed; a knuckle of small bowel was incarcerated in the obturator foramen and the serosa was tearing. The small bowel was successfully reduced with gentle traction and primary suture repaired. The bowel was well perfused and peristalsing.
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A transabdominal preperitoneal (TAPP) repair with mesh was then performed. This was done by developing peritoneal flaps, identifying the obturator foramen, and reducing the hernia sac. Five by five cm of Prolene mesh was secured to Cooper’s ligament using 0 Ethibond interrupted sutures with extracorporeal Weston knots. The peritoneal flap incorporating the hernia sac was then closed using a running 2-0 Stratafix suture.
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The patient tolerated the procedure well. On post operative day one she was mobilizing, tolerating oral intake, and her pain was controlled without use of narcotics. She was discharged postoperative day 2 with return of her bowel function. She recovered well from the surgery with no acute postoperative complications.
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Preliminary video of this patient’s surgery: https://youtu.be/ewrcQ4GSYKM
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POINTS OF DISCUSSION:
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1. Approach to repair of obturator hernia: Anterior vs posterior approach to repair. Laparoscopic vs open approach to repair.
2. Mesh vs no mesh for emergency repair of obturator hernia.
3. For TAPP repair: Type of mesh, how mesh is secured, and how peritoneum is closed.
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WHY IS THIS CASE INTERESTING:
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Obturator hernia is an uncommon presentation, most often seen in older women. There is no standardized technique and many variations in technical details have been reported. This is a case presentation of a novel minimally invasive approach with a detailed outline of the surgical technique employed. This was a successful case with no intraoperative or early postoperative complications.
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Selection Criteria: (1) Clinical relevance to emergent hernia repair. (2) Originality (3) Learning points on emergency hernia repair.