Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
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On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : PD01 - PD04 Full Version

Little Old Lady’s Hernia with Hiatus Hernia- A Case Report


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55189.16352
N Nasida Fathima, Sushanto Neogi, Manu Vats, Surya Elangovan

1. Junior Resident, Department of General Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India. 2. Professor, Department of General Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India. 3. Assistant Professor, Department of General Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India. 4. Junior Resident, Department of General Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India.

Correspondence Address :
Dr. Manu Vats,
Assistant Professor, Department of General Surgery, 2nd Floor, BL Taneja Block, Maulana Azad Medical College, 2, Bahadur Shah Zafar Marg, New Delhi-110002, India.
E-mail: vatsmanu@gmail.com

Abstract

With the outbreak of the Coronavirus Disease-2019 (COVID-19) pandemic, it is not uncommon to see patients who present with respiratory symptoms secondary to an abdominal pathology, being suspected of having COVID-19. Here, authors report a case of an 80-year-old female who presented with recent-onset dyspnoea, shortness of breath, pain abdomen and non passage of flatus and stools. Examination revealed that the patient had tachycardia, tachypnoea, and dyspnoea with an oxygen saturation (SpO2) of 92%. Her abdomen was distended, non tender with no free fluid detected. All the hernial orifices were free. Computed Tomography (CT) scan revealed a left diaphragmatic hernia and a left-sided obturator hernia with obstructed ileal segment. However, intraoperatively a Type IV hiatus hernia was discovered, where the Gastrooesophageal (GE) junction, stomach, colon, and omentum were the contents. This case highlights an unusual clinical presentation of a rare cause of intestinal obstruction and its management during the COVID-19 pandemic. Obstructed obturator hernia is associated with high morbidity and mortality.

Keywords

Digestive system surgical procedures, Intestinal, Obstruction, Obturator

Case Report

An 80-year-old lady presented to the emergency department during the COVID-19 pandemic, with dyspnoea, shortness of breath, abdominal pain, vomiting and non passage of flatus and stools. In view of the respiratory complaints, she was admitted to a COVID-19 suspect ward, and a general surgery consult was sought. The patient gave a history of fall from one flight of stairs, five years ago, for which medical consultation was not taken. She had no previous complaints of retrosternal discomfort, heartburn, regurgitation or haematemesis.

On examination, the patient was tachycardic, tachypnoeic and dyspnoeic with SpO2 of 92%. Her abdomen was distended, non tender with no evidence of free fluid; bilateral inguinal and umbilical areas did not reveal any hernia. No mass was palpable on digital rectal examination. The patient underwent all routine investigations including a chest X-ray, Non Contrast Computed Tomography (NCCT)-abdomen and Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) for COVID-19. The patient was administered oxygen by face mask and a nasogastric tube was inserted to decompress the stomach. Her chest X-ray revealed dilated bowel loops with air-fluid levels within the left hemithorax, with contralateral mediastinal shift (Table/Fig 1). Abdominal X-ray showed dilated small bowel loops suggestive of small intestinal obstruction (Table/Fig 2).

The NCCT scan demonstrated a left-sided diaphragmatic hernia along with a left-sided obstructed obturator hernia (Table/Fig 3), (Table/Fig 4). The diaphragmatic defect measured 5.3×7.4 cm through which the GE junction, stomach, along with proximal small bowel loops and splenic flexure of colon had herniated into the thoracic cavity. The dilated stomach was positioned against the posterior ribs and the posterior costophrenic recess was obliterated on dependent position- the dependent viscera sign. Contralateral tracheal mediastinal shift and atelectasis of basal segments of the left lower lobe was also noted. The CT scan also reported herniation of an ileal segment and omental fat between obturator and pectineus muscles on the left-side suggestive of an obturator hernia. It also revealed dilatation of proximal ileal loops measuring approximately 3.7cm in calibre suggestive of obstruction. There was no evidence of any intraperitoneal free air foci. The RT-PCR for COVID-19 was reported negative.

With a provisional diagnosis of an obstructed left obturator hernia and left-sided diaphragmatic hernia, the patient was taken up for an emergency exploratory laparotomy. To our surprise, abdominal exploration revealed a large defect measuring approximately 7×9 cm in the left paraesophageal membrane (Table/Fig 5) with GE junction, stomach, small bowel, and omentum herniating through it into the chest suggestive of a type IV hiatal hernia (Table/Fig 6) (1). In the left lower abdomen, an ileal loop (150 cm from ileocaecal junction) was found herniating through a defect in the left obturator membrane (3×2 cm). Multiple jejunal diverticulosis was also found (Table/Fig 7).

The herniated contents (GE junction, stomach, small bowel, and omentum) were reduced through the diaphragmatic defect after ensuring an adequate length of intra-abdominal oesophagus. Primary repair of the hiatal defect was done using non absorbable (polypropylene) interrupted sutures and a left-side tube thoracostomy was done. After closure of the defect, a gastropexy (fundus hitched to lateral abdominal wall) was done to maintain the position of the stomach and prevent recurrence. The herniated ileal segment was reduced after the obturator membrane aperture was widened. The herniated ileal segment was gangrenous and already perforated (Table/Fig 8). Resection of the gangrenous segment and an end-to-end anastomosis of ileum were done, along with primary closure of obturator defect using interrupted polypropylene suture.

The patient could not be extubated postoperatively due to poor respiratory effort. She was shifted to the Intensive Care Unit (ICU) after the procedure and remained on mechanical ventilation for the next two days. The patient was administered antibiotics and a prophylactic dose of low molecular weight heparin subcutaneously in view of prolonged duration of surgery. The patient was extubated and shifted back to the surgical ward on Post Operative Day (POD) 3. During the early postoperative period, she complained only of mild surgical site pain. The output from the abdominal drain and thoracostomy tube was serous in nature and was progressively decreasing. On postoperative day 6, she developed sudden onset respiratory distress, and tachycardia. An Arterial Blood Gas (ABG) analysis showed refractory respiratory alkalosis. She was intubated again and shifted to ICU and put on mechanical ventilation.

However, in spite of our best efforts, she succumbed to death within a few hours, the cause may have been pulmonary thromboembolism.

Discussion

Obturator hernia is defined as the protrusion of intraperitoneal or extraperitoneal contents through the obturator canal (2). Obturator hernias make up only 0.05-2.2% of all hernias (3). Although rare, it has the highest mortality rate amongst all hernias (4). Establishing a preoperative diagnosis is a challenge, and it is often missed due to paucity of clinical features that are commonly observed in other inguinal and ventral wall hernias (5). With ageing, there is thinning of fat in the obturator canal, increasing the likelihood of herniation in women of the age group 70-90 years. Obturator hernia is thus also known as ‘little old lady’s hernia’ (6). The clinical features are often vague and include vomiting, lower abdominal pain, and obstipation. The Howship-Romberg sign (lancinating pain accentuated by extending, abducting, and internally rotating the hip due to obturator nerve impingement) is considered pathognomonic but is only found in approximately 15-50% of patients (7). A mass felt per vaginum or per rectal examination, in addition to the above findings strongly favours this diagnosis. In some patients, there occur frequent episodes of intestinal obstruction without any lump in the groin. The diagnosis is either confirmed with the help of a CT scan or during exploratory surgery.

In an extensive review of 43 patients of obturator hernia encountered over a time span of 31 years, Kammori M et al., observed that a majority of patients had presented with signs and symptoms of acute intestinal obstruction and a positive Howship-Romberg sign. Lower midline laparotomy was done in all cases and the herniated small bowel segment was reduced after widening the obturator aperture. Resection and anastomosis of the small bowel was done in cases where the small bowel was found gangrenous. The authors used interrupted or purse string sutures to close the defect in 20 patients, the ovary or the uterus in 20 patients and the prosthetic mesh in three patients. Complications during the postoperative period were seen in 37 patients. The authors proposed that early diagnosis using CT scan improved patient prognosis and reduced the incidence of gut resection (8).

Preoperative CT scan accurately picked up obturator hernia in all 10 patients in one such study. All 10 patients underwent surgery and recovered (9). In fact, establishing an early diagnosis with the help of a CT scan and following it up with an immediate laparotomy/laparoscopy has a favourable prognosis (10). However, on a rare occasion, an obstructed obturator hernia may be masked by an overlying inguinal hernia and be missed on a CT scan. Diagnostic laparoscopy can be useful in such cases (11). Laparoscopic repair (transabdominal preperitoneal) is also a viable option where expertise is available (12). It was observed that non survivors had elevated levels of blood urea, constipation greater than two days, low urine output, significantly longer operative time, and increased postoperative complications (12),(13). Although majority of obturator hernias are repaired using a mesh, it is not advocated in cases where the bowel is strangulated or perforated. In such cases, the hernial sac is ligated using continuous non absorbable sutures and the foramen is closed using biological or synthetic material (14). In index case, patient had gangrene of the small bowel segment and therefore, the use of mesh was avoided due to a higher risk of infection and rejection.

Four types of hiatus hernia have been described in literature (Table/Fig 6) (1). A patient with a Type IV hiatus hernia may clinically present with heartburn, regurgitation, progressive dysphagia, chest pain and nausea/vomiting (15). Atypical signs and symptoms include fatigue, severe anasarca due to mass effect, orthopnoea, postprandial GE reflux, hypoxemia, and aspiration pneumonia (16). Rarely, a patient may present to the Emergency Department (ED) with complaint of a sharp retrosternal pain. Cardiac cause of pain must be ruled out with utmost urgency in such a case (17). In index case, patient presented with dyspnoea, shortness of breath, and abdominal pain.

Management of a patient with type IV hiatus hernia depends on the severity of the disease, and condition of the herniated viscera. This may vary from a conservative approach at one end of the spectrum (17), to a procedure involving extensive resection of the necrosed herniated contents at the other end (15). There are several important considerations while performing the surgical repair. Laparoscopic approach, in experienced hands, helps in better visualisation of the hiatus, allowing the dissection of the oesophagus and the hernial sac in the mediastinum under endoscopic vision, and an earlier postoperative recovery (18). However, laparoscopic repairs have been found to be associated with remarkably higher recurrence rates compared to the open approach (19). Irrespective of the approach, the first step is dissection of the hernial sac from the mediastinal structures. This allows successful reduction of the hernia whilst avoiding an iatrogenic oesophageal injury. This step also reduces the risk of early recurrence. Full sac excision, though technically demanding, is recommended as it has been shown to reduce early recurrence. However, excision of sac and repair of large hernial defects increase the probability of injury to the vagus nerve, leading to gastroparesis (20). In index case, the sac in the patient was fully excised.

It is also important to ensure tension free closure of the diaphragm. This reduces the risk of recurrence due to reopening of the defect and is accomplished with the help of a mesh in large defects. The mesh is used to cover the defect itself or to reinforce the crura. Mesh reinforcement of a large hiatal hernia is associated with decreased short-term recurrence. However, available literature lacks a consensus on recommendations for uniform usage of mesh. Complications associated with mesh repair, such as local erosion into the oesophagus and oesophageal stenosis, lead to higher dysphagia rates (20). In index patient, the oesophageal hiatus was 7 cm in diameter and was relatively firm. Therefore, only suture cruroraphy was performed to avoid mesh-related complications. In case excess tension is anticipated across the diaphragm after repair, a relaxing incision may be given on the diaphragmatic crura. Typically, a fundoplication is done with a hiatus hernia repair, which helps not only in restricting any visceral transposition through the repaired defect, but also in strengthening the Lower Oesophageal Sphincter (LES) to prevent reflux disease (20). However, a fundoplication was not deemed necessary in index patient as the length of the oesophagus was adequate.

No report in existing medical literature was found describing the presence of both obturator and type IV hiatus hernia in one patient. As evident from present report, both hernias can be managed by surgical repair during exploratory laparotomy. Exploration and reduction of contents followed by resection anastomosis or stoma creation (depending on the bowel condition), and surgical closure of the defect are the recommended steps for the repair of an obstructed obturator hernia. Reduction of contents, excision of redundant sac, tension free repair of the hiatal defect with or without mesh (as indicated) and vagal preservation constitute the key components of a type IV hiatal hernia repair.

Conclusion

When an elderly female presents with obstipation and no significant signs in abdomen, one should not hesitate in obtaining a CT scan immediately. Early and prompt diagnosis followed by timely surgical intervention is likely to ensure a favourable prognosis. However, morbidity and mortality in cases presenting with strangulated obturator hernias alongside a type IV hiatal hernia remains high.

Acknowledgement

The authors would like to thank Dr. Nitin Sood, Consultant Radiology for assistance with the radiological images.

Consent: Taken from the next of kin (husband).

References

1.
Yeo CJ. Shackelford’s Surgery of the Alimentary Tract. 8th ed. Philadelphia: Elsevier; c2019. Chapter 74, Internal Hernias: Congenital and Acquired; p. 280.
2.
Igari K, Ochiai T, Aihara A, Kumagai Y, Iida M, Yamazaki S. Clinical presentation of obturator hernia and review of the literature. Hernia. 2010;14:409-13. [crossref] [PubMed]
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Thanapaisan C, Thanapaisal C. Sixty-one cases of obturator hernia in Chiangrai Regional Hospital: Retrospective study. J Med Assoc Thai. 2006;89:2081.
4.
De Clercq L, Coenegrachts K, Feryn T, Van Couter A, Vandevoorde P, Verstraete K, et al. An elderly woman with obstructed obturator hernia: A less common variety of external abdominal hernia. Journal Belge de Radiologie. 2010;93(6):302. [crossref] [PubMed]
5.
Peter R, Indiran V, Kannan K, Maduraimuthu P, Varadarajan C. Rare case of obturator hernia in a patient with Marfan’s syndrome. Hernia. 2014;18:439-42. [crossref] [PubMed]
6.
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DOI and Others

DOI: 10.7860/JCDR/2022/55189.16352

Date of Submission: Jan 25, 2022
Date of Peer Review: Mar 03, 2022
Date of Acceptance: Mar 28, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 28, 2022
• Manual Googling: Mar 20, 2022
• iThenticate Software: Mar 26, 2022 (5%)

ETYMOLOGY: Author Origin

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