Editing Obturator hernia

== '''Anatomy/pathophysiology''' ==

* Obturator canal - 1cm wide, 2-3cm long tunnel between obturator externus and internus muscles
* Obturator foramen - space between pubic rami and ischial bones, covered by obturator membrane in all but anterior superior aspect
* Obturator nerve, artery and vein travel through the canal. Nerve divides into anterior and posterior branches within the canal
* Obturator hernia is a protrusion through the obturator canal and foramen
** Develops through a widening defect of the obturator externus and internus muscles, coursing along either anterior or posterior branch of nerve
** Symptoms occur more commonly with compression of anterior branch

== '''Presentation''' ==

* Rare but high-risk - gangrenous bowel seen in up to half of repairs
* Female to males of 6:1 - larger and more oblique incline of the obturator canal in the female pelvis
* More common on right - left side protected by sigmoid colon
* Typical patient is an emaciated elderly woman with intermittent bowel obstruction and weight loss
* Usual hernia risk factors and multiparity
* Howship-Romberg sign: referred pain down the medial thigh to the knee through compression of the obturator nerve with extension, abduction and medial rotation that is relieved by flexion of the thigh
* CT is best

== '''Management''' ==

* Require rapid surgical repair
* Open best for emergency cases, but laparoscopic IPOM/TAPP is better for elective
* TEP is no good

=== '''Open''' ===

* Intraperitoneal approach 
* Lower midline incision
* Hernia often well incarcerated and difficult to reduce - steep Trendelenburg and gentle persistent retraction. Can incise obturator membrane.
* Close defect primarily around obturator vessels with nonabsorbable suture, with approximation of periosteum of the superior pubic ramus and internal obturator muscle
* Coated synthetic mesh placed into the defect and secured with interrupted suture to pectineal ligament and fascia overlying pubic symphysis
* Can sometimes use local flaps to close defect e.g. periosteum or uterine ligament

=== '''Laparoscopic TAPP/IPOM''' ===

* Periumbilical Hasson
* Two 5mm trocars on each side of umbilicus lateral to semilunar line
* Gentle water pressure through a catheter placed into obturator foramen adjacent to the bowel may help reduce it
* TAPP - incise peritoneum from ipsilateral ASIS toward the medial umbilical ligament, and peel towards the obturator foramen with enough space to allow mesh placement
* IPOM - peritoneum not incised

[[Category:Abdo wall and retroperitoneum]]