Strangulated right obturator hernia causing small bowel obstruction in an elderly woman with bilateral obturator hernias and a positive Howship-Romberg sign: a case report.

INTRODUCTION AND IMPORTANCE: Obturator hernia is a rare but potentially life-threatening cause of mechanical small-bowel obstruction, predominantly affecting elderly women. Delayed diagnosis is common because of a nonspecific presentation, and strangulation frequently necessitates emergency surgery. CASE PRESENTATION: An 84-year-old woman presented with diffuse abdominal pain, abdominal distension, nausea, vomiting, oral intolerance, constipation, and a positive Howship-Romberg sign. Contrast-enhanced computed tomography demonstrated bilateral obturator hernias, with an incarcerated right-sided small-bowel loop associated with obstruction and free fluid. Emergency surgery was performed through an infraumbilical midline laparotomy. A right obturator hernia containing ischemic distal ileum was identified and manually reduced. Approximately 10 cm of nonviable small bowel was resected, followed by a hand-sewn, end-to-end ileoileal anastomosis in two layers with 3-0 polyglactin 910, which was located approximately 250 cm from the angle of Treitz. The obturator defect, measuring approximately 1 cm, was repaired by primary closure with 3-0 polyglactin 910. Mesh was not used because bowel resection increased the risk of contamination. Histopathology confirmed ischemic intestinal injury with necrosis. The postoperative course was favorable. CLINICAL DISCUSSION: This case emphasizes the importance of recognizing the Howship-Romberg sign and the value of computed tomography for preoperative diagnosis. It also illustrates that an obturator hernia may occur in patients without the classic emaciated phenotype. In the emergency setting, open transperitoneal surgery allows bowel assessment, resection when needed, and definitive repair of the defect. CONCLUSION: An obturator hernia should be considered in elderly women presenting with intestinal obstruction, particularly when the Howship-Romberg sign is present. Early diagnosis by computed tomography and urgent surgical management are essential to reduce morbidity and mortality.