P-451: Obturator hernia presenting as a cause of recurrent pain in a patient with previously diagnosed endometriosis

Abstract

To describe a patient with recurrent pelvic endometriosis who was discovered to have an obturator hernia at the time of laparoscopy. Case report. A 47 year old multiparous Caucasian woman with a 10 year history of chronic pelvic pain and laparoscopically diagnosed endometriosis presented with complaints of constant, right-sided pelvic pain, localized to a pin-point area in her right pelvis. She also noted a pulling sensation down the anterior and posterior surfaces of her right leg, dyspareunia and dysmenorrhea, but no gastrointestinal complaints. Six years ago, she had undergone laparoscopic fulguration of pelvic endometriosis and bilateral tubal ligation. Her pain had improved for 8-12 months post-operatively, but recurred thereafter and remained persistent. Subsequent treatment was with oral contraceptive pills taken continuously. The patient enrolled in a clinical protocol studying the Neural Immune Mechanisms and Genetic Influences of Chronic Pelvic Pain and endometriosis. As part of the study protocol, the patient underwent a laparoscopy which revealed a right obturator hernia in addition to endometrial implants in the anterior and posterior cul-de-sac, left ovarian fossa and left uterosacral ligament. The proximal portion of both fallopian tubes were surgically absent and the ovaries appeared normal. Endometriotic implants were excised with Nd:YAG laser. The obturator hernia contained peritoneum, but no bowel. The redundant peritoneum was everted, excised and Marlex mesh was used to seal the defect. Two weeks post-operatively, the patient noted some improvement of her pain. Controversy exists as to the optimal treatment for recurrent pain associated with endometriosis with many arguing for use of medical therapy rather than repeat surgery. In a setting of recurrent pain in a patient with previously diagnosed endometriosis, it is easy to assume that pain is due to disease recurrence. In this particular situation, however, this patient became symptomatic on medical treatment. At surgery, it was difficult to attribute the pain definitively to either endometriosis or the hernia. Yet, an obturator hernia would not have been discovered unless she had laparoscopic surgery. Late diagnosis of obturator hernia has been associated with bowel obstruction and morbidity and mortality reported as high as 25%. In patients with recurrent chronic pelvic pain, physicians should also consider non-gynecologic etiologies. The threshold to perform a laparoscopy should be low, especially in those not responding to medical treatment. It is critical to balance the risks of laparoscopy with the risks of missing treatable disease. The consequences of missed diagnosis may be life-threatening in some cases.