STRANGULATED OBTURATOR HERNIA WITH INTESTINAL PERFORATION IN A NONAGENARIAN: A CASE REPORT

Background: Obturator hernia is a rare pelvic hernia, accounting for less than 1% of abdominal wall hernias, and predominantly affects frail, elderly, multiparous women. Its insidious clinical presentation and high rate of strangulation make imaging, particularly computed tomography (CT) , central to timely diagnosis.
Case Presentation: We report the case of a 95-year-old woman with a four-day history of small bowel obstruction and left inner thigh pain, with a positive Howship-Romberg sign. Laboratory tests showed leukocytosis (14,000/mm³) and elevated C-reactive protein (100 mg/L).
Imaging Findings: Contrast-enhanced CT of the abdomen and pelvis demonstrated dilated small bowel loops (up to 42 mm) with an abrupt transition point at the left obturator foramen, where a loop of bowel was incarcerated between the pectineus and obturator externus muscles, medial to the femoral vessels, through a narrow neck, findings diagnostic of a strangulated left obturator hernia. No CT sign of bowel ischemia (mural thickening, reduced enhancement, fat stranding, pneumatosis or free fluid) was identified.
Management and Outcome: Emergency laparotomy revealed an 8-cm segment of necrotic small bowel with a 1-cm perforation, despite the reassuring CT appearance, illustrating the limits of CT for predicting bowel viability. Segmental resection with primary manual anastomosis and hernia repair using a round ligament flap were performed. The postoperative course was complicated by a superficial surgical site infection and a fixed evisceration, both managed conservatively, with a favorable overall outcome.
Conclusion: CT is the imaging modality of choice for suspected obturator hernia, offering excellent sensitivity for hernia detection and anatomical characterization. However, its ability to predict bowel viability remains imperfect, and a reassuring CT should not delay surgical exploration in a symptomatic elderly patient with biological signs of inflammation.