Obturator Hernia: A Critical Appraisal of Treatment Strategies Based on 10 Cases and Current Literature: Towards a Pragmatic Surgical Algorithm

Obturator hernia is a rare pelvic hernia that predominantly affects elderly, thin women. Despite advances in imaging and surgical techniques, the optimal surgical approach remains controversial. We retrospectively analyzed 10 patients who underwent emergency surgery for an obturator hernia at our institution between January 2010 and August 2024. All patients were female with a median age of 88.9 years (range: 84-97). Six patients (60%) required bowel resection. Seven underwent open repairs, and three underwent laparoscopic transabdominal preperitoneal (TAPP) repair. One patient with perforated peritonitis died postoperatively. During a median follow-up of 32 months (range: 18-51), one recurrence occurred at 34 months in a patient who had undergone suture repair without mesh reinforcement. Based on our experience and a comprehensive literature review encompassing three systematic reviews/meta-analyses and one nationwide registry study, we propose a treatment algorithm centered on three principles: TAPP as the default approach, bowel viability as the central decision point, and a contamination-based repair strategy. Two illustrative cases demonstrate the clinical application of this algorithm.