Department of Surgery, Mt. Sinai St. Luke’s-Roosevelt Hospital Center, New York, NY, USA (all authors)

ABSTRACT

Introduction: Obturator hernias represent a rare cause of small-bowel obstruction. When diagnosed on computed tomographic (CT) scan in a stable patient, timely surgical repair is indicated. Because of the absence of large-scale studies, the ideal operative approach has yet to be defined.

Case Description: A 75-year-old woman presented to the emergency department with an incarcerated left-side obturator hernia manifesting as a small-bowel obstruction. The hernia was diagnosed on CT scan, and the patient was taken to the operating room for laparoscopic reduction and repair. During surgery, a contralateral obturator hernia and bilateral indirect inguinal hernias were discovered. Hybrid transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) approaches were used to reduce and demonstrate the viability of the incarcerated bowel and then to repair all 4 defects with mesh. The procedure was well tolerated, and the patient was discharged uneventfully after the return of bowel function.

Discussion: This case provides an example of how a hybrid TAPP/TEP laparoscopic approach can be effective for visualizing and repairing an obturator hernia as well as an incidentally discovered inguinal hernia.

Key Words: Obturator hernia, TEP, TAPP, Mesh repair

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Department of Surgery, Veterans Affairs Central Iowa Health Care System, Des Moines, IA, USA (Dr. Staab). Surgery Residency Program of the Iowa Methodist Medical Center, Des Moines, IA, USA (Dr. Welander).

ABSTRACT

Minimally invasive surgical technology is changing the management of spigelian hernias. In addition to open repairs, laparoscopic transabdominal repairs as well as laparoscopic totally extraperitoneal repairs are well documented. However, because spigelian hernias are uncommon, few surgeons have a large volume of experience with spigelian hernia repairs. This is particularly true of the repair of spigelian hernias with concurrent inguinal and femoral hernias. We provide intraoperative images of bilateral spigelian and inguinal and femoral hernias repaired via a laparoscopic totally extraperitoneal approach. This patient was successfully treated with a single piece of mesh on each side. The single mesh piece on the right repaired the right spigelian hernia and a femoral hernia. The single mesh piece on the left repaired the spigelian hernia and left direct and indirect inguinal hernias. Preoperative computed tomography scans illustrate the close proximity of the spigelian defects and the inguinal defects that allow the use of a single 10 15-cm mesh piece for repair of each side. Our goal is to provide intraoperative images to allow a surgeon who is experienced with totally extraperitoneal repairs to visualize this operation and apply this approach to other patients with concurrent spigelian and inguinal or femoral hernias.

Key Words: Spigelian hernia, Laparoscopic, Minimally invasive surgery, Totally extraperitoneal repair, Inguinal hernia, Femoral hernia, Mesh repair.

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