the hernia sac passes through the obturator foramen , following the path of the obturator nerves and muscles . here
we present a typical case of obturator hernia which was diagnosed by spiral ct preoperatively and the emergency operation was performed successfully .
a 78-year - old woman was sent to our emergency department because of recurrent abdominal pain and constipation for 10 days .
the colicky pain was getting worse in recent nearly six days , accompanied with nausea and vomiting .
she also complained of intermittent right hip pain with radiation to the medial aspect of the thigh for several months , which worsened with extension , abduction , or internal rotation of right leg .
the body weight was 38 kg . physical examination revealed a distended abdomen without tenderness or muscle guarding .
the abdominal plain film revealed small intestine obstruction . enhanced ct scan demonstrated obvious intestinal obstruction with a low density mass in the right obturator canal area ( figure 1 )
the diagnosis of right obturaor hernia was confirmed and emergency laparotomy was performed . during the operation ,
a 10 cm loop of small intestine was revealed herniated into the right obturator canal ( figure 2 ) .
the incidence is nearly 1% of all hernias 2 . with the nickname  little old lady 's hernia 
, it usually occurs in multiparous and elderly emaciated women due to a wider pelvis and enlarged obturator canal .
the patient had a positive howship - romberg sign , which was caused by the intermittent irritation of the obturator nerve .
it was reported that 15~50% patients of obturator hernia may have positive howship - romberg sign 1 . in her early course
the loss of the adductor reflex , named as hannington - kiff sign , was observed on the affected side , while the patellar tendon reflex was intact on the same side 3 .
various imaging examinations have been applied to establish the diagnosis , including ultrasonography , herniography , ct scan and so on . among them , ct scan has superior sensitivity and accuracy 4 . in our case , preoperative diagnosis of obturator hernia was confirmed by spiral ct scan and emergent operation was performed .
chang et al concluded that the duration of symptoms was one of the major factors affecting the rate of bowel resection .
there are a variety of operative approaches including inguinal , retropubic and transperitoneal approach 6,7 .
laparotomy via low midline incision was applied in this case because it had advantages of better exposure and facilitation of bowel resection when necessary .
the advantages of laparoscopic surgery include less postoperative pain , shorter hospital stay and lower complications .
however , it is usually reserved for the nonstrangulated hernia because of more challenging techniques and longer learning curve .
methods of repair include simple suture closure , closure of the obturator with adjacent tissue , and mesh replacement during laparotomy 9 .
many authors preferred a simple closure of the hernial defect with one or more interrupted sutures , in case of bowel resection 6 , 8 .
in this case we did the simple suture and outcome was satisfying . in conclusion , it should be kept in mind that obturator hernia is a rare but significant cause of intestinal obstruction especially in emaciated elderly women .
 obturator hernia is a rare pelvic hernia with incidence of 1% . 
 it 's a significant cause of intestinal obstruction in emaciated elderly women . delayed diagnosis and surgical intervention contributed to its relatively high morbidity and mortality . 
 we present a typical case of obturator hernia with positive howship - romberg sign and hannington - kiff sign . 
 the diagnosis was confirmed by spiral ct preoperatively . during the emergency laparotomy , 
 the incarcerated intestine was reduced and removed . 
 obturator foramen was repaired by simple suture . 
 the patient recovered uneventfully and no recurrence occurred during the follow - up . 
 the obturator hernia should be included in the differential diagnosis if clinically suspected . 
 early diagnosis and prompt surgical treatment are essential to reduce the morbidity and mortality associated with obturator hernia . 
Introduction
Case report
Discussion