Obturator hernia misdiagnosed as inguinal incarceration: a case of postoperative small-bowel perforation and subcutaneous fecal emphysema.

INTRODUCTION AND IMPORTANCE: An obturator hernia is a rare condition accounting for less than 1% of abdominal wall hernias. Due to its deep pelvic location and nonspecific clinical presentation, it is frequently misdiagnosed, most often as an inguinal hernia. Delayed or incorrect diagnosis may result in bowel ischemia and perforation.

CASE PRESENTATION: We report the case of a 61-year-old man who underwent emergency open surgery at another institution for a presumed strangulated right inguinal hernia with placement of prosthetic mesh. No operative report was available regarding intraoperative findings, bowel assessment, or mesh positioning. Eight days later, the patient presented with progressive abdominal distention, respiratory distress, and extensive subcutaneous emphysema involving the cervical and thoracic regions. A CT scan demonstrated pneumoperitoneum, bilateral pneumothorax, pneumomediastinum, and an incarcerated obturator hernia with small-bowel ischemia and a suspected perforation. Emergency laparotomy revealed a perforated ileal loop associated with extensive fecal contamination tracking through fascial planes in proximity to the previously placed mesh. Segmental bowel resection with double stoma, obturator defect closure, and drainage were performed. The postoperative course was favorable.

CLINICAL DISCUSSION: This case illustrates several rare and clinically relevant issues: (1) an obturator hernia mimicking an inguinal hernia; (2) a complex postoperative course with bowel perforation in the context of recent mesh repair; and (3) extensive subcutaneous fecal emphysema with thoracic extension. However, in the absence of operative documentation from the initial surgery, it remains impossible to determine with certainty whether the obturator hernia was initially unrecognized, whether ischemia evolved secondarily, or whether the perforation occurred independently in the postoperative period. This uncertainty highlights the importance of caution in attributing postoperative complications to a single causal mechanism when complete clinical data are unavailable.

CONCLUSION: Obturator hernia remains a diagnostic challenge in emergency surgery. In cases of persistent postoperative obstruction after groin hernia repair, alternative diagnoses should be considered. This case also underlines the importance of complete operative documentation and close postoperative follow-up. Subcutaneous fecal emphysema represents an exceptionally rare but severe manifestation of gastrointestinal perforation.