Knee Pain and Small Bowel Obstruction

Ryan Bly, Hira Hasnain. Western Michigan University School of Medicine

Objective: Diagnosis of obturator hernia is difficult and is often made at laparotomy for small bowel obstruction. The following video demonstrates some of challenges in diagnosis of this condition as well as a surgical option in management of a case with delayed presentation associated with strangulated bowel.

Methods: An 87-year-old female, with history of atrial fibrillation on coumadin, presented to the emergency department (ED) with persistent right knee pain of 4 days duration. She had an episode of vomiting & abdominal discomfort 3 days prior to presentation. No bowel movement in 2 days. She denied any trauma.On physical exam, mild knee tenderness with no obvious deformity. Abdomen is soft, mildly distended but not tender. No masses in groin or medial thigh. WBC was normal & INR was 4.8. A knee & pelvic x-rays showed no evidence of fracture. A CT of abdomen and pelvis showed a small bowel obstruction secondary to incarcerated right obturator hernia.

Procedure: After optimization and reversal of anticoagulation, she was taken to the Operating Room for laparoscopic reduction of obturator hernia. The incarcerated segment showed a focal full thickness transmural necrosis with perforated bowel. Because of contamination, a primary repair was chosen. Small bowel resection of compromised segment with primary anastomosis was performed. 

Result: The patient did well after surgery. Diet was advanced as tolerated.  Anticoagulation was resumed. She was discharged POD 9 to a rehab facility.

Conclusion: High index of suspicion is imperative in early diagnosis of, and subsequent intervention for, obturator hernia in elderly patient. Laparoscopic primary repair is safe and effective especially with small defects and in case of contamination.