© 2009 Canadian Medical AssociationCan J Surg, Vol. 52, No. 3, June 2009
CONTINUING MEDICAL EDUCATION
FORMATION MÉDICALE CONTINUE
Dr. J.C. Muthusami
Department of Surgery Unit 1
General and Head and Neck Surgery
Christian Medical College
Tamil Nadu, India
fax: 91 416 2232035, 91 416 223 2103
Perforated obturator Littre hernia
Tarun J. Jacob, MB BS
Pranay Gaikwad, DNB, MNAMS
Amit J. Tirkey, MS
Janakiraman Rajinikanth, MS,
John P. Raj, MS
John C. Muthusami, MS
From the Department of Surgery Unit 1,
General and Head and Neck Surgery,
Christian Medical College, Vellore,
632004, Tamil Nadu, India
eckel diverticulum and obturator hernia are rare causes of intesti-
nal obstruction. We present the unique case of an elderly woman
with acute abdomen secondary to the coexistence of both these
A 75-year-old woman presented with a 5-day history of abdominal pain,
constipation and vomiting. Her symptoms followed acute gastroenteritis,
which was managed conservatively at another centre. She was also experienc-
ing obscure pain in her right knee.
On examination, her body mass index was 16, and she was dehydrated.
Abdominal examination revealed central distention with visible bowel coils.
There were no signs of peritonism, but bowel sounds were absent. External
hernial sites were normal. Pelvic examination revealed a full-thickness rectal
prolapse and complete uterine procidentia.
Her total white blood cell count was 13.4 × 109/L, and her serum albumin
level was 5 g/L. A contrast-enhanced spiral computed tomography (CT) scan
of the abdomen confirmed the plain abdominal radiographic finding of dilated
small bowel loops in addition to an abrupt termination at the terminal ileum.
With a working diagnosis of acute small bowel obstruction, the patient
underwent laparotomy pending a final report by the senior radiologist (Fig. 1).
Laparotomy revealed a perforated Meckel diverticulum herniating into
the obturator canal. The neck of the hernia formed a ring of constriction at
the base of the diverticulum where it had perforated (Fig. 2). In view of the
Fig. 2. Perioperative photograph illustrating perforation (notched
arrow) at the base of a congested Meckel diverticulum (chevron)
identified at 2 feet from the appendix (bold arrow).
Fig. 1. Computed tomography scan showing a right obturator
hernia (thin arrow) containing a perforated Meckel diverticulum.
Contralateral pectineus (bold arrow) and obturator externus
(notched arrow) muscles are depicted for comparison.
patient’s age and other comorbid factors, we resected the
ileal segment containing the perforated Meckel diverticu-
lum and fashioned an end-ileostomy with closure of the
distal loop. Postoperatively, the patient required ventila-
tion and total parenteral nutrition. She recovered well, left
the hospital in 2 weeks, and re-established intestinal conti-
nuity 3 months later. She declined any treatment of the
rectal and uterine prolapse.
Obturator canal hernia has a reported incidence of 1%.1
This hernia passes through the obturator foramen, follow-
ing the path of the obturator nerves and muscles. Clinical
diagnosis of an obturator hernia is extremely difficult,
notwithstanding the 4 cardinal clinical signs: acute in-
testinal obstruction, pain in the right hip radiating to the
anterior aspect of the thigh and knee (the Howship–
Romberg sign), repeated episodes of bowel obstruction
that resolve without intervention and a palpable mass in
the proximal medial aspect of the thigh. Other less com-
mon signs include the loss of the adductor reflex due to
compression of the obturator nerve, eponymously known
as the Hannington–Kiff sign; ecchymoses in the upper
medial thigh due to effusion from strangulation; and a
mass palpable laterally on vaginal examination. The pa-
tient, often a multiparous, elderly woman, is debilitated
and wasted. This presentation has earned it the nickname,
“little old lady’s hernia.”
Obturator hernias occur with a female-to-male ratio of
6:1 and may be bilateral in 6% of cases. A wider pelvis and
larger obturator canal in women could explain this. The
hernia most commonly contains small bowel. Methods of
repair vary from a simple suture closure or biological tissue
closure (using autogenous tissue like broad ligament, ovary
or uterus) to polypropylene mesh placement during either
a laparotomy or laparoscopy. Mortality in obturator hernia
is 11%–70%, among the highest noted in the abdominal
Littre described Meckel diverticulum in a hernia in
1700.2–4A true Littre hernia contains a Meckel diverticu-
lum alone, but a mixed Littre hernia contains ileum or
other abdominal viscera as well. Perforation may be due to
either peptic ulceration or compromised circulation and lu-
minal patency at the narrow neck of the hernia. A literature
review suggests that a Littre hernia can occur in femoral,
ventral, paraumbilical, sciatic and lumbar hernias, and even
as a complication of a laparoscopic port-site hernia.5
Our patient’s case highlights that a Littre hernia can
also arise in an obturator hernia and that it needs a high
degree of clinical suspicion as well as a CT scan to confirm
diagnosis. The interesting aspect of our patient’s case was
the perforation of the Meckel diverticulum and its hernia-
tion into the obturator canal. To our knowledge, ours is
the first report in the published English-language literature
that highlights one of the rarest positions for a perforated
1.Green BT. Strangulated obturator hernia: still deadly. South Med J
Yip AW, AhChong AK, Lam KH. Obturator hernia: a continuing
diagnostic challenge. Surgery 1993;113:266-9.
Yokoyama Y, Yamaguchi A, Isogai M, et al. Thirty-six cases of obtu-
rator hernia: Does computed tomography contribute to postopera-
tive outcome? World J Surg 1999;23:214-6.
Meyerowitz BR. Littre’s hernia. BMJ 1958;1:1154-6.
Ahmad K, Shaikh FM, Ng SC, et al. Laparoscopic port Littre’s
hernia: a rare complication of Meckel’s diverticulum. Am J Surg
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Competing interests: None declared.