Obturator hernia is more common in thin elderly women . Many cases present reduced operative resistance such as dehydration from ileus and aspiration pneumonia after vomiting. If reduction is not successful, laparotomy or intestinal resection by emergency surgery is performed even under poor general conditions. Laparotomy being extremely invasive for the elderly, increases the frequency of postoperative complications leading to prolonged hospital stay and in turn, and reduces patient's Activities of daily living(ADL) . Therefore, since emergency surgery when the general condition is poor may lead to unfortunate outcomes, it is considered important to determine whether conservative treatment is possible or surgical treatment should be performed. If conservative treatment is possible, it is possible to preoperatively intervene for factors of perioperative complications (cardiovascular disease, pneumonia, and malnutrition). In strangulated obturator hernia, the elapsed time from onset of the disease till diagnosis and treatment are often unknown. In those cases, emergency surgery is necessary due to damage to the strangulated intestinal tract. However, within 12 cases of strangulated obturator hernia in our study, none of the 10 cases that could be reduced under echo guidance showed any physical findings suggesting intestinal damage and abnormal laboratory values. Conversely, the intraoperative findings of two patients whose hernia could not be reduced under echo guidance indicated that manual surgery was not possible; thus, they underwent intestinal resection. Based on the above results, the possibility of a reduction under echo guidance was the determining factor in performing emergency surgery. The onset of delayed gastrointestinal perforation after reduction was feared, so follow-up hospitalization was necessary, under the condition, where surgical intervention could be done, if needed. In all patients, we tried to perform echo-guided reduction when confirmed diagnosis of obturator hernia as the cause of abdominal pain or ileus. There is no exclusion criterion for patients who perform this echo-guided reduction, and we think that it may be performed in all cases, also as a diagnostic treatment. We think that gastrointestinal damage for allows elective surgery if reduction under echo-guide is possible, and that gastrointestinal damage for emergency surgery is occurring if reduction under echo-guide is not possible. According to successful cases of manual reduction of strangulated obturator hernia, there are cases in which manual reduction only and in which transvaginal manual reduction . However, non-invasive manual reduction only may cause complications such as thigh bleeding . When the diagnosis of obturator hernia was confirmed by CT, it is considered that reduction of the hernia, while confirming it in real time by echo-guide will lead to successful reduction of strangulated obturator hernia. In addition, obturator hernia is considered for emergency surgery and cannot be treated leniently. When trying with ultrasound-guided for obturator hernia, the treatment strategy is limited to 10 min per doctor, and if it could not be reduced, change to another physician and trying for an additional 10 min. If it takes longer than this, the policy is to perform emergency surgery without hesitation.
In general, laparotomy is the most common approach to radical obturator hernia surgery. However, reports of using transabdominal preperitoneal repair (TAPP) and totally extraperitoneal endoscopic repair (TEP) as the first choices are increasing [5, 6]. Compared to open surgery, laparoscopic surgery may be particularly useful for elderly people who have had relatively long periods of poor eating or ileus before surgery, in terms of insensible water loss, effects of postoperative pain on respiration and recovery of postoperative gastrointestinal motility . In strangulated obturator hernia, dilation of the intestinal tract due to ileus may hinder visual field securing when performing procedures such as TAPP. Therefore, if a reduction is possible under echo guidance, normal TAPP procedures can be performed when dilatation of the intestinal tract has diminished. If reduction under echo-guide is possible, strangulated obturator hernia is effective, because the range of treatment expand; however, the possibility of emergency surgery should always be considered.