Radiologic imaging of herniation of the small bowel through a defect in the broad ligament

Usefulness of early diagnosis of small bowel obstruction due to broad ligament hernia using multidetector computed tomography: a case report

Small bowel obstruction due to broad ligament hernia (BLH) is a rare type of internal hernia. Preoperative diagnosis is difficult, as clinical symptoms and imaging results are often nonspecific. BLH has a high risk of strangulation and requires surgery for the reduction of herniated bowels. According to an analysis of 140 BLH cases reported in Japan, the typical patient is a middle-aged woman who has been pregnant and has no history of abdominal surgery and the characteristic computed tomography (CT) findings. This report will enable preoperative early diagnosis with our description of the typical patient with BLH and the characteristic CT findings. Tortuousness and dilation of the ovarian veins were noted in three cases, including in ours. This may be used as a new CT feature of early detection. Additionally, we report a case of BLH successfully treated after early diagnosis using multidetector CT.

An incarcerated internal hernia of the sigmoid colon through a defect in the broad ligament: A case report

Introduction and importance

Hernias through a defect of the broad ligament are rare, accounting for only 1.6–5% of internal herniations [1]. This report describes a rare case of sigmoid colon obstruction due to hernia through a defect of the broad ligament, which was diagnosed before surgery.

Case presentation

A 78-year-old multiparous woman presented with lower abdominal pain and nausea. Contrast-enhanced multi-detector CT (MDCT) demonstrated a dilated sigmoid colon and edematous mesentery of the sigmoid colon in the left Douglas' fossa, the uterus was compressed dorsally to the right and the left ovary was compressed ventrally. We diagnosed an internal broad ligament defect hernia with incarceration of the sigmoid colon, and performed emergency laparotomy. The necrotic sigmoid colon was resected and anastomosis was performed by the double stapling technique. The postoperative course was uneventful.

Clinical discussion

We consider the treatment of hernia of sigmoid colon through a broad ligament defect.

Conclusion

We recognize that there is a possibility that, in addition to the small intestine, proximally located organs may be incarcerated. In the case of the colon, we should choose the treatment method carefully according to whether or not the colon is expected to be necrotic.

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Hernia of the sigmoid colon through a broad ligament defect is rare.

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The approach is based on whether or not the sigmoid colon is necrotic.

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We can evaluate whether it is necrotic or not and reposition by colonoscopy.

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Anatomically proximal organs may be incarcerated through such defects.

A review of internal hernias related to congenital peritoneal fossae and apertures

Congenital-type internal hernias have the potential to cause small bowel obstruction well into adulthood. Congenital-type internal hernias include left paraduodenal, right paraduodenal, foramen of Winslow, pericecal, sigmoid mesocolon, transomental, small bowel mesentery, and broad ligament hernias. This review summarizes CT imaging features and complications of congenital internal hernias using a systematic approach based on abdominopelvic quadrants and key anatomic features. CT imaging will continue to be commonly used to evaluate abdominal pain. Anatomical landmarks and characteristic CT findings can help identify congenital internal hernias as a potential cause of abdominal pain.

Strangulated small-bowel internal hernia through a defect in the broad ligament of the uterus presenting as acute intestinal obstruction: A case report

Background

Internal hernias rarely lead to bowel obstruction; they are caused by a natural or unnatural opening within the peritoneal cavity. Defects in the broad ligament are extremely rare. Patients present with features of intestinal obstruction and most cases are diagnosed during surgery.

Case presentation

A 62-year-old parous woman presented with epigastric pain and attacks of vomiting for 1 week. The patient had had constipation for the last 5 days. She had no history of abdominal surgery. Abdominal examination revealed a distended abdomen with evidence of generalized abdominal tenderness.

Abdominal CT scan showed evidence of intestinal obstruction. During laparotomy there were dilated small-bowel loops with an evidence of internal hernia through a 3 cm × 3 cm defect in the left broad ligament, through which a segment of strangulated terminal ileum was passing. Resection of the strangulated bowel was performed with end-to-end intestinal anastomosis. The broad ligament defect was closed with a slowly absorbable suture material.

Conclusion

Surgery for intestinal obstruction due to internal hernias should follow the same principles of any case of intestinal obstruction, whether performed by the open conventional technique or laparoscopically. Surgery should not be delayed, to avoid increased morbidity and mortality. During surgery it is mandatory that the surgeon looks for any other possible defects and close them to avoid recurrence. Internal hernias caused by broad ligament defects are best managed by either closure of the defect or salpingectomy; the course of the ureter must be identified during surgery to prevent injury.

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Internal hernias caused by broad ligament defects are very rare.

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The defect in the board ligament may be unilateral or bilateral.

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Cystic remnants of müllerian ducts may rupture and result in such defects.

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Most cases are diagnosed intraoperatively.

Recurrence hernia in the broad ligament of the uterus: a case report

Background

Bowel herniation through a defect in the broad ligament of the uterus is a rare disease and few cases of recurrence have been reported. We report herein a recurrence case of a patient with broad ligament hernia (BLH), along with a review of the literature.

Case presentation

A 53-year-old woman complaining of abdominal pain was transported to our hospital. She had a history of laparotomy for small-bowel obstruction associated with hernia in the broad ligament of the uterus 10 years ago at a local hospital. Abdominal pelvic contrast-enhanced computed tomography revealed that the mesentery of the dilated bowels converged at a thick band in the pelvis, suggesting closed loop obstruction of the small bowel. The patient underwent urgent laparotomy and was diagnosed with bowel herniation through an opening in the broad ligament of the uterus on the right side, which was ipsilateral with the previous surgery. The hernia orifice was widened by incision and incarcerated bowel segments were released and preserved because ischemia was reversible. The membranous defect of BLH was closed by suture with braded silk strings.

Conclusions

Although BLH is a rare disease, patients face a significant risk of disease recurrence. Nonabsorbable suture may be advisable for closure of the hernia orifice in BLH.

Suspensory Ligaments of the Female Genital Organs: MRI Evaluation with Intraoperative Correlation

The uterus, which plays an important role in the reproductive process, provides a home for the developing fetus and so must be in a stable, though flexible, location. Various structures with suspensory ligaments help provide this berth. MRI with high spatial resolution allows us to detect and evaluate these relatively fine structures. Under physiologic conditions, MRI can be used to depict uterine and ovarian ligaments (ie, the uterosacral, cardinal, and round ligaments, as well as the suspensory ligament of the ovary). In the presence of pathologic conditions (inflammation, endometriosis, tumors), the suspensory ligaments may appear thickened or invaded, which makes their delineation easier. Understanding the normal anatomy of the suspensory ligaments of the female genital organs and using a standardized nomenclature are essential for identifying and reporting related pathologic conditions. The female pelvic anatomy and the suspensory ligaments of the female genital organs are described as depicted with MRI. Also, the compartmental anatomy of the female pelvis is explained, including the extraperitoneal pelvic spaces. Finally, a checklist is provided for structured reporting of the MRI findings in the female pelvis. Online supplemental material is available for this article. ^©RSNA, 2018.

Small bowel obstruction secondary to internal hernia through a defect of the broad ligament: preoperative multi-detector CT diagnosis

We report a case of small bowel obstruction secondary to internal hernia through a defect in the broad ligament diagnosed by MDCT and confirmed at surgery. The CT findings that allow the diagnosis of this very rare cause of SBO are presented here.

Utility of multi-detector CT for pre-operative diagnosis of internal hernia through a defect in the broad ligament (2007: 1b)

Internal hernia through a defect in the broad ligament is a rare cause of intestinal obstruction, and pre-operative diagnosis is generally difficult. Here, we report our experience in which multi-detector computed tomography (MDCT), which allows direct recognition of incarcerated small bowel, was useful in the pre-operative diagnosis of this hernia.

CT of internal hernia through a defect of the perirectal fossa

We report a case of internal hernia due to a peritoneal defect of the perirectal fossa. This condition is extremely rare and has been reported in the literature only once. This is the first independent case report. CT findings as well as the differential diagnosis of the condition are discussed.

CT of internal hernias

Computed tomography (CT) plays an important role in diagnosis of acute intestinal obstruction and planning of surgical treatment. Although internal hernias are uncommon, they may be included in the differential diagnosis in cases of intestinal obstruction, especially in the absence of a history of abdominal surgery or trauma. CT findings of internal hernias include evidence of small bowel obstruction (SBO); the most common manifestation of internal hernias is strangulating SBO, which occurs after closed-loop obstruction. Therefore, in patients suspected to have internal hernias, early surgical intervention may be indicated to reduce the high morbidity and mortality rates. In a study of 13 cases of internal hernias, nine different types of internal hernias were found and the surgical and radiologic findings were correlated. The following factors may be helpful in preoperative diagnosis of internal hernias with CT: (a) knowledge of the normal anatomy of the peritoneal cavity and the characteristic anatomic location of each type of internal hernia; (b) observation of a saclike mass or cluster of dilated small bowel loops at an abnormal anatomic location in the presence of SBO; and (c) observation of an engorged, stretched, and displaced mesenteric vascular pedicle and of converging vessels at the hernial orifice.

Strangulated hernia through a defect of the broad ligament and mobile cecum: A case report

We report a case of 28-year-old woman presenting with small bowel obstruction. She had neither prior surgery nor delivery. An upright abdominal radiograph revealed several air-fluid levels in the small bowel in the midabdomen and the pelvic cavity. Computed tomography demonstrated a dilated small bowel loop in the Douglas’s fossa, but no definite diagnosis could be made. Supportive therapy with draining the intestinal fluid by a long intestinal tube did not result in improvement, which suggested the possibility of a strangulated hernia. Exploratory laparotomy revealed mobile cecum and a 20-cm length of the ileum herniated into a defect of the right broad ligament. As a gangrenous change was recognized in the incarcerated bowel, its resection was carried out, followed by end-to-end anastomosis and closure of the defects of the broad ligament. The postoperative course was uneventful. Intestinal obstruction is a very common cause for presentation to an emergency department, while internal hernia is a rare cause of obstruction. Among internal hernias, those through defects of the broad ligament are extremely rare. Defects of the broad ligament can be either congenital or secondary to surgery, pelvic inflammatory disease, and delivery trauma. In conclusion, we emphasize that hernia of the broad ligament should be added to the list of differential diagnosis for female patients presenting with an intestinal obstruction. Early diagnosis and surgical repair reduce morbidity and mortality from strangulation.

Internal herniation through a defect of the broad ligament of the uterus

Internal herniation through a defect of the uterine broad ligament is rarely encountered. We report a case of a 52-year-old woman in whom a closed bowel loop with approximation of its ends to the uterus was the definitive computed tomographic finding. This type of internal herniation should be considered in the differential diagnosis of female patients presenting with ileus.

Internal hernia through a defect in the broad ligament: a rare cause of intestinal obstruction

Internal hernias through the broad ligament are an extremely rare cause of intestinal obstruction. Clinical symptoms and imaging are often nonspecific, making preoperative diagnosis difficult. The authors report a case in which multidetector computed tomography proved useful in the preoperative diagnosis.