obturator hernia
Introduction
Introduction to obturator The peritoneal visceral device protrudes from the femoral triangle through the closed hole of the hip bone, which is called obturator. The obturator tube is a fibrous bony tube with a length of 2 to 3 cm. It is inclined forward, inside and below. The upper part of the tube is composed of a closed sulcus under the pubic symphysis. The lower part is covered by the pelvic sarcolemma and the closed hole. The closed pore membrane of the upper edge of the muscle is formed by joining. The obturator membrane is a fibrous diaphragm, the fibers are arranged in an irregular cross, and the outer membrane and the inner membrane are covered. The inner mouth (pelvic mouth) is covered with peritoneal and extraperitoneal tissues, and the outer mouth is open to the internal femoral and femoral arteries. The triangular area formed by the pubic bone. There are obturator nerves and obturator veins in the obturator tube to reach the inner side of the thigh. Therefore, when there is sputum prolapse, there are often symptoms of obturator nerve compression. The obturator artery comes from the internal iliac artery, but a small part comes from the lower abdominal wall artery. The edge of the ligament of the sac is passed, and the inside of the inguinal ligament is inadvertently injured during the operation, and uncontrolled bleeding can occur. basic knowledge The proportion of sickness: 0.01% Susceptible people: no specific people Mode of infection: non-infectious Complications: intestinal obstruction peritonitis toxic shock syndrome
Cause
Obstacle spasm
Local tissue is weak (30%):
Closed-cell tube provides a potential channel for the occurrence of obturator sputum, but it does not necessarily occur. Only local tissue is weak, such as rupture of the obturator muscle, displacement to the caudal side or abnormal obturator membrane. It is possible to form sputum under the action of the sac, and the sac can be directly protruded through the ruptured obturator muscle, or the obturator and the obturator vessel can be worn out of the obturator or the obturator. The outer muscle protrudes below.
Degeneration of pelvic floor tissue (20%):
This sputum occurs in elderly patients, mostly in the 70 to 80 years old, Larrieu et al reported that the average age of onset is 67 years old, which may be related to the degeneration of the elderly tissue leading to physiological pelvic fascia relaxation, pelvic floor muscle atrophy.
Closed tube wide (10%):
Closed-hole sputum female patients are more common, which is more related to female obturator than male, straight, physiologically due to multiple pregnancies, increased intra-abdominal pressure, can also cause female perineum too loose and wide.
Weight loss (10%):
Multiple ills, malnutrition, weight loss, and any wasting disease can cause the perforation of the peritoneal adipose tissue to be lost in the closed mouth of the obturator, and the peritoneum covering the upper part of the peritoneum is easily depressed to form a hernia sac.
Increased intra-abdominal pressure (5%):
The diseases that cause an increase in intra-abdominal pressure include chronic bronchitis, long-term cough, and habitual constipation.
Pathogenesis
1. The formation of closed cells in the formation process is divided into three stages:
1 There is extraperital fat at the obturator.
2 There is a shallow peritoneal depression, and gradually deepens to form the hernia sac.
3 The sac is full of contents.
The sputum content of the obturator is mainly the small intestine. It can be part of the intestinal wall (Richter's sputum) or the intestine, and its contents can also be bladder, ovary, fallopian tube, appendix, colon and Meckel room and so on.
2. There are 3 ways to highlight the path:
1 The sac is passed through a closed-cell tube and is removed under the pubic muscle.
2 The sac is in the middle of the obturator muscle, between the upper muscle bundle, along the obturator nerve and the lower branch of the artery.
3 The sac is moved forward and downward, from the closed hole, between the outer membrane, but in any case, the location is very deep, unless the sac is large, it is not easy to lick and mass in the thigh.
3. Pathophysiology Closed hole is a narrow fibrous duct, the surrounding tissue is hard and flexible, and there are obturator nerves (waist 2 ~ 3) through it, when the viscera or tissue is released by the closed hole, due to the hernia sac and content The crowdedness of the object will inevitably oppress the obturator nerve, and there will be intermittent pain in the thigh and knee joint, soreness, numbness and other discomfort. The vast majority of the obscurus sputum is the small intestine, and the ankle ring is small and inelastic. Therefore, the intestinal tube that is invaded is prone to incarceration, and blood circulation disorder occurs in a short period of time, and intestinal narrowing and necrosis occur. Therefore, symptoms of small intestinal obstruction appear after clinical knee pain, and if the contents of the intestine are partially invaded by the intestinal wall, There was no obvious intestinal obstruction in the early stage, and the sputum was small and located deep in the pubic muscle, which was difficult to find.
Prevention
Obturator prevention 1. Maintain an optimistic and happy mood. Long-term mental stress, anxiety, irritability, pessimism and other emotions will make the balance of the cerebral cortex excitatory and inhibition process imbalance, so you need to maintain a happy mood. 2, life restraint pay attention to rest, work and rest, life orderly, maintain an optimistic, positive, upward attitude towards life has a great help to prevent disease. Do the regularity of tea and rice, live daily, not overworked, open-minded, and develop good habits. 3, reasonable diet can eat more high-fiber and fresh vegetables and fruits, balanced nutrition, including protein, sugar, fat, vitamins, trace elements and dietary fiber and other essential nutrients, meat and vegetables, diversified food varieties, Giving full play to the complementary role of nutrients in food is also helpful in preventing this disease.
Complication
Obturator complication Complications, intestinal obstruction, peritonitis, toxic shock syndrome
Older patients are slow to respond to pain, often due to inability to prompt diagnosis and treatment, sputum content is narrowed, strangulated intestinal obstruction, diffuse peritonitis, toxic shock, etc., delay in treatment, intestinal necrosis, femoral abscess and Intestinal fistula, according to foreign scholars, intestinal necrosis, intestinal perforation rate of 50%, mortality rate of 13% to 40%; domestic reports, intestinal necrosis, intestinal perforation incidence rate of up to 80%, mortality rate of 12% to 75%.
Symptom
Symptoms of obturator sputum Common symptoms Obsessed nerve damage Howship... Abdominal tension constipation Sensation bloating abdominal pain
Initiation of obturator nerve compression is followed by symptoms of intestinal obstruction.
Symptom
(1) Howship-Romberg sign: When the obturator nerve is pressed close, the groin area and the anterior medial thigh appear tingling, numbness, soreness, and radiate to the inner side of the knee. When coughing, stretching the leg and abducting, external rotation, As the adductor muscle pulls on the obturator muscle, the pain is aggravated (the obturator nerve is stressed), and the opposite is called the Howship-Romberg sign. The incidence of this sign in the obturator is 20.2%. ~100% range.
In the early stage of obturator or a small number of incomplete intestinal wall ticks (Richter) can be intermittent abdominal pain and femoral, knee joint muscle pain or soreness discomfort, Somell et al also found that in addition to obturator neuralgia In the case of obturator hernia, a region of about 10 cm above the inner side of the knee can be found in a hypersensitivity area.
(2) Symptoms of intestinal obstruction: 93.7%-100% of patients with obturator hernia have symptoms of intestinal obstruction. Because the obturator is composed of bone and tough aponeurosis, the position is deep and narrow, and the ankle ring lacks elasticity. Most patients have a block. Small but not obvious, mainly for abdominal pain, bloating, vomiting, stopping bowel movements and other intestinal obstruction performance, a small number of manifestations of chronic incomplete intestinal obstruction.
2. Signs
(1) Howship-Romberg sign: extensor leg extension, external rotation, groin and anterior medial thigh pain.
(2) Examination of the upper part of the femoral triangle and the fossa ovalis, about 20% of patients can reach a round mass with local tenderness.
(3) Rectal or vaginal finger examination, some patients can find the closed area of the anterior wall of the affected pelvis, there is a cord-like mass, and when there is a strangulation, if the limb is abducted, the pain of the mass is obviously aggravated.
(4) Because the sputum is small and deep, it is not easy to be detected, and the rectum is far from the closed hole. Therefore, some patients are easily detected by vaginal examination.
(5) Incarceration occurs in obturator hernia. After strangulation, the affected side of the lower abdomen and the suprapubic area may have obvious signs of peritonitis such as abdominal muscle tension, tenderness and rebound tenderness.
Examine
Closed hole inspection
When clinical complications occur, there will be a positive finding in the laboratory test, and the white blood cell count will increase.
X-ray inspection
(1) Abdominal and pelvic X-ray film: The following image features:
1 general intestinal obstruction image performance.
2 The small intestine and gas-liquid plane of the proximal obstruction were fixed above the pelvic pubic bone. After changing the position, the sign was not changed.
3 There is gas in the closed hole or an inflated bowel, and the blind end points to the closed hole. This is the typical X-ray appearance of the closed hole.
(2) sac sac angiography: adapted to the intermittent appearance of intestinal obstruction symptoms, the sac of the obturator sac can be observed during the interstitial sac.
(3) CT scan: CT scan is helpful for the diagnosis of this disease. There is a low-density dense shadow between the obturator muscle and the pubis muscle when the pelvic scan is not incarcerated. The mass of the tumor shows a distinct gas density and intestinal tube. Expansion; after incarceration, the intestinal shadow can be seen from the inside of the closed hole into the closed hole, and the intestinal tube above the intestinal shadow in the closed hole has signs of intestinal obstruction, and the closed hole can be diagnosed.
2. B-ultrasound showed abnormal intestinal reflex waves in the tender part.
Diagnosis
Diagnosis of obturator
Diagnostic criteria
Obscuration of the obturator is insidious, local signs are not obvious, and many patients with acute intestinal obstruction of unknown origin are admitted to the hospital. Therefore, the preoperative diagnosis is difficult, and the misdiagnosis rate is as high as 70%. The clinician should think of the disease, carefully analyze the medical history, and combine the disease. Clinical features and X-ray findings can be diagnosed correctly.
1. History of medical history
(1) Older women, who are thin, may have a similar history of seizures, multiple pregnancy and childbirth, habitual constipation and other medical history should be highly vigilant.
(2) In the early stage of the attack, knee pain, soreness and other symptoms of intestinal obstruction are present, and it has the characteristics of general sputum, that is, sudden onset when the intra-abdominal pressure is increased, and relieved after lying or resting.
2. Signs
(1) The Howship-Romberg sign is the earliest and most characteristic sign of this disease, and it is also the main basis for preoperative diagnosis. Especially for elderly and frail women with intestinal obstruction and Howship-Romberg sign, should be considered The disease.
(2) The inside of the fossa ovalis under the inguinal ligament can be combined with a round mass with mild tenderness, but only some patients can find this sign.
(3) When rectal or vaginal examination, there may be a cord-like mass on the anterior wall of the pelvis, and there is tenderness; however, when the tumor is not obvious, the disease cannot be ruled out.
3. Auxiliary examination of the abdomen and pelvis X-ray plain film showing the upper pubic rim fixed in the shadow of the inflatable bowel or closed gas in the closed hole or an inflated bowel, the blind end points to the closed hole, the obstruction of the cystic sac can be observed in the gap The hernia sac, CT sometimes helps to confirm the diagnosis.
Differential diagnosis
The comprehensive literature of obturator is often misdiagnosed as the following diseases, which need to be carefully identified.
1. Intestinal obstruction: The obturator is small and deep, and severe abdominal pain is easy to cover up other symptoms. The main points of identification of intestinal obstruction caused by non-obturited hernia are:
1 No Howship-Romberg sign.
2 rectal or vaginal finger examination on the pelvic side wall without cords and tenderness.
3 Abdominal and pelvic X-ray examination, no obscuration with enhanced transmittance in the anterior pubic symphysis, CT examination, no pedicle shadow on the outer mouth of the obturator tube.
2. Peritonitis: It is often easy to diagnose Richter's sputum as peritonitis. Because the sputum is partially invaded by the intestinal wall, there is no obvious intestinal obstruction. The bottom of the sac is far away from the body surface, and the mass is small, which is easy to delay diagnosis and cause intestinal tract. Wall narrowing necrosis, and easily misdiagnosed as peritonitis, but peritonitis
1 No Howship-Romberg sign.
2 There is no tender cord-like mass at the inner mouth of the closed wall of the pelvic wall of the rectum or vaginal.
3 imaging findings without obturator sputum.
3. Rheumatoid arthritis, sciatica, lumbosacral pain, obturator, obturator, obstructive stenosis, initial symptoms of obturator neuralgia, often misdiagnosed as rheumatoid arthritis, sciatica, lumbosacral pain, etc. The disease has no Howship-Romberg sign and intestinal obstruction symptoms, combined with rectal or vaginal finger examination, X-ray examination, etc. can be distinguished.
4. Femoral hernia: the sacral mass protrudes from the fossa ovalis on the inner side of the femoral vein, and the obturator sac is protruded through the obturator in the deep layer of the pubic plexus, protruding at the lower end of the femoral triangle, combined with rectal or vaginal examination, on the affected side pelvis The anterior wall touches the cord or block with tenderness, the abducted limb, the mass is prominent, and the tenderness is aggravated, which is helpful for diagnosis.
5. Acute appendicitis: Richters Intestine wall intestine wall incarceration, patients still have venting, defecation, incarceration, intestinal necrosis, inflammatory exudation stimulates right lower quadrant tenderness with elevated body temperature, easily misdiagnosed as acute appendicitis, but acute Appendicitis often had metastatic right lower abdominal pain, positive colonic inflation test, early no intestinal obstruction, no Howship-Romberg sign, rectal or vaginal finger examination of the affected anterior pelvic wall without cord-like mass with tenderness.
6. Ureteral calculi: abdominal cramps and radiation pain, hematuria, B-ultrasound, CT, IVU can show renal pelvis, ureteral hydrops and ureteral calculi, but no intestinal obstruction and Howship-Romberg sign, rectal or vaginal examination, abdomen And the pelvic X-ray film also has no relevant performance of this disease.
