Bilateral obturator herniae and associated femoral hernia.

Case A well nourished 43-year-old female presented with intestinal obstruction and a tender irreducible left femoral hernia. A viable loop of ileum was released from the hernia via a low inguinal approach and the small bowel proximal and distal were carefully examined. The femoral hernia was repaired and the patient made a slow but steady recovery, being discharged on the sixth postoperative day. Eight days after her discharge, symptoms of further intestinal obstruction recurred and the patient was admitted for observation. No mass was palpable in the left iliac fossa or groin but bowel sounds were obstructive and fluid levels with dilated small bowel loops were present on erect abdominal X-rays. The obstruction did not settle on conservative treatment and a laparotomy was performed. This revealed a loop of ileum strangulated within a large left obturator hernia medial to the vessels and nerve. A small bowel resection was performed and the defect repaired with peritoneum. On the right side an empty obturator hernia was present, medial to the vessels and nerve, which admitted the terminal phalanx of an index finger. This sac was reduced and excised and the defect closed with interrupted nylon sutures. Postoperatively the patient made an uneventful recovery. Comment Over 500 cases of obturated hernia have been reported since de Ronsil first recognized the condition in 1722. They are 6 times more common in females than males and are usually seen in the seventh or eighth decade. A history of multiple pregnancies and obesity followed by dramatic weight loss is often present. Most patients present with intestinal obstruction or vague abdominal pains, and about 50% have pain on the medial side of the knee (Howship-Romberg sign) due to pressure on the obturator nerve. Few obturator herniae are diagnosed before surgery. Gray and Skandalakis (1978) describe 3 stages in the development of an obturator hernia: (1) the entrance of pre-peritoneal fat; (2) the entrance of peritoneum, and (3) the entrance of a viscus into the obturator canal. In the case reported, coexisting second and third stage obturator herniae were present. Hanley and Hanna (1970) reported 2 cases of bilateral obturator herniae, both in females. Gray records 2 patients with a single obturator hernia and a co-existing inguinal or femoral hernia. The overall mortality of this rare condition is 13%, most of which is due to cardiorespiratory disease in a group of patients in their seventh or eighth decades. The present combination of bilateral obturator herniae and a femoral hernia has not been previously reported.