obturator hernias ( ohs ) are rare ; they represent only 0.051.4% of all abdominal wall hernias . the typical patient with an
women are affected nine times more frequently than men , because of broader pelvis with a larger triangular obturator canal opening with a greater transverse diameter , and a history of pregnancy .
additional contributing factors are multiparity , chronic illness , malnutrition and conditions associated with increased intra - abdominal pressure .
a 88-year - old woman presented to the ed with abdominal pain , vomiting , right hip pain and diarrhoea .
medical co - morbidities include ischaemic heart disease , hypertension and bilateral osteoarthritis of the hip .
her surgical history includes three caesarean sections , open cholecystectomy , umbilical hernia repair and left mastectomy for breast cancer . a computed tomography ( ct ) abdomen revealed small bowel obstruction due to the right oh ( fig .  1 ) and
a trial of conservative management was made for patient due to her age , multiple co - morbidities and patient 's wishes .
the patient re - presented 1 month later with small bowel obstruction and pain radiating down medial left leg .
abdominal x - ray was consistent with small bowel obstruction ( fig .  2 ) and
intra - operatively , there was a large right oh containing a small bowel , which was reduced , and a bard polypropylene mesh plug inserted into the defect and fixed with prolene interrupted sutures .
the patient made an unremarkable recovery , and she was discharged 3 days after the operation .
figure  1:(a and b ) small bowel obstruction secondary to a right oh . ( a ) coronal and ( b ) axial . 

figure  2:abdominal x - ray showing dilated small bowel loops and severe osteoarthritis changes in both hips . 

figure  3:(a and b ) small bowel obstruction secondary to a left oh . ( a ) coronal and ( b ) axial .
( a and b ) small bowel obstruction secondary to a right oh . ( a ) coronal and ( b ) axial . abdominal x - ray showing dilated small bowel loops and severe osteoarthritis changes in both hips .
( a and b ) small bowel obstruction secondary to a left oh . ( a ) coronal and ( b ) axial .
it occurs when viscera herniates through the obturator canal , through which the obturator vessels and nerve pass to reach the hip .
three stages of oh formative have been described : ( 1 ) pre - peritoneal connective tissue and fat enter the obturator canal ; ( 2 ) a dimple is formed in the peritoneum over the internal orifice of the obturator canal and progresses to the invagination of a peritoneal sac and ( 3 ) viscera , typically ileum , enters the sac . in an emaciated patient ,
the loss of protective pre - peritoneal fat over the obturator canal increases the risk of herniation .
according to a case series of 30 patients by mayo clinic , the most common presenting signs and symptoms were bowel obstruction ( 63% ) , abdominal / groin pain ( 57% ) and a palpable lump in medial aspect of thigh ( 10% ) .
romberg sign , which is pain along the distribution of the obturator nerve , is present in 37% of patients .
high morbidity in oh is directly related to the advanced age of the patients , diagnostic delay , gangrene and bowel perforation , deterioration and disability of the patients , and associated chronic diseases [ 7 , 8 ] . as such , conservative management has little or no place in the management of oh , as is proved in our case where conservative management did eventually fail .
the early diagnosis is challenging when the symptoms and signs are non - specific . among the various radiologic diagnostic modalities ,
ct scan has superior sensitivity and accuracy , as it allows definitive diagnosis of oh before laparotomy , and it can also show incarcerated bowel in the obturator foramen , with contrast scans having the ability to demonstrate any ischaemia or infarction . in a setting where ct is not available , plain abdominal radiographs can show signs of bowel obstruction , and ultrasound examination may reveal a hypoechoiec mass reflecting a dilated oedematous bowel segment .
oh repair is usually accomplished by a midline laparotomy and primary repair . however , with the advent of laparoscopy , additional choices of mesh , and the possibility of a pre - operative diagnosis , other options for repair now exist .
laparoscopic repair is only suitable for elective repairs , mostly when oh presents as an incidental intraoperative diagnosis during a laparoscopic hernia repair or other pelvic operation .
a midline laparatomy was applied in this case because it has the advantages of better exposure and facilitation of bowel resection when necessary .
we used a prosthetic plug to reinforce the obturator foramen in one side and a simple primary closure for the other side , and the outcome was satisfying .
after reduction of the contents , it is necessary to check the viability of the bowel and perform segmental resection of ischaemic or gangrenous areas . in conclusion ,
they should always be suspected when a thin elderly woman presents with symptoms of bowel obstruction or non - specific pain over the thigh and hip .
 obturator hernia ( oh ) is a rare type of pelvic hernia 
 . it can cause significant morbidity and mortality , especially in the elderly age group . 
 delayed treatment is associated with high rates of strangulation ( 25100% ) . 
 we present an 88-year - old woman who presented with symptoms of bowel obstruction and right hip pain . 
 computed tomography ( ct ) abdomen revealed bilateral ohs and bowel obstruction secondary to the right oh . she was managed conservatively due to her age and co - morbidities and her bowel obstruction subsequently resolved . 
 she was discharged , only to re - present 1 month later with similar complaints . 
 a repeat ct scan revealed bilateral ohs and bowel obstruction due to the left oh . she underwent midline laparatomy and both ohs were reduced . 
 the right oh was fixed with polypropylene mesh plug and the left oh was fixed with primary closure . 
 the patient recovered and no recurrence was noted during follow - up . 
INTRODUCTION
CASE REPORT
DISCUSSION