Laparoscopic management of small bowel incarceration caused by a broad ligament defect: report of a case

Holes can be perilous: A rare presentation of intestinal obstruction - Herniation through the broad ligament

A 57-year-old lady presented with symptoms of intestinal obstruction preceded by a 2-day history of lower abdomen pain. Clinically, she had a distended abdomen with tenderness in her lower abdomen. Laboratory investigations were unremarkable. An abdominal radiograph showed a dilated small bowel with no extensive bowel gas. A computed tomography (CT) scan showed suspected intestinal obstruction secondary to herniation into the right broad ligament. The decision was made to proceed with surgery, and the intraoperative results confirmed the CT results. The literature review is outlined here, and this instance illustrates a surprising discovery.

Herniation Through Defects in the Broad Ligament

Background

We sought to assess hernia characteristics and classification through comprehensive review of the literature involving broad ligament herniation.

Methods

A literature search via MEDLINE and Embase databases was conducted to identify and select broad ligament herniation studies published between January 1, 2000 and September 30, 2020. Extracted data included previous surgical history, previous obstetric history, diagnostic imaging, herniated organ, hernia classification, and repair performed. The reported data has been compared to a unique case of broad ligament herniation that presented to our institution.

Results

A total of 44 articles with 49 cases were identified for the study. Eighteen (36.7%) patients had a history of previous abdominal surgery while 29 (59.2%) had a history of previous childbirth. Type I (51.0%) and Type II (18.4%) defects were most commonly reported with most patients reporting only one defect (85.7%) using the Cilley classification. Twenty-nine patients underwent primary laparoscopic repair of the defect while 19 patients underwent exploratory laparotomy.

Conclusions

The analysis of previously reported cases adds to the limited literature on broad ligament hernias and highlights the surgical management of this uncommon pathology. It also highlights the need for a broad differential diagnosis when female patients present with pelvic pain or symptoms of small bowel obstruction. The broad ligament should be fully inspected when mesenteric defects are suspected as multiple defects can be present as evidenced by the attached case study.

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.

Needlescopic surgery for broad ligament hernia: A case report

Broad ligament hernia is a rare type of internal hernia. We herein report a case of broad ligament hernia successfully treated by needlescopic surgery. A 41-year-old woman was referred to our hospital with a complaint of nausea and vomiting. Abdominal contrast-enhanced computed tomography showed diffuse dilatation of the small bowel accompanied by a caliber change at the right side of the uterus. She was thus diagnosed with small bowel obstruction due to incarceration through right broad ligament hernia. After bowel decompression, she underwent elective needlescopic surgery using 2- and 3-mm instruments. The defect in the right broad ligament was closed with sutures, and she was discharged 2 days after surgery. In the treatment of broad ligament hernia without bowel ischemia, neither an abdominal incision nor any energy devices are required. In this respect, needlescopic surgery seems to be a promising approach among minimally invasive surgeries.

Acute abdominal pain due to internal herniation of the sigmoid colon, fallopian tube and left ovary, a rare presentation of Allen Masters syndrome

In 1955, Allen and Masters describe a painful syndrome which associates traumatic delivery to laceration found on the posterior leaf of the broad ligament. Herniation through this defect is a rare entity, accounted for about 4-7% of all internal hernias. Normally, it involves the small bowel. The authors present the case of a multiparous woman admitted at emergency for constipation and abdominal pain. The CT scan showed an extremely rare case of internal hernia of the sigmoid colon, fallopian tube and left ovary through a large defect of the broad ligament. The patient underwent a full laparoscopic surgery that allowed the reduction of the hernia and the suture of the defect with very good outcome.

Broad ligament hernia successfully repaired by single-incision laparoscopy: A case report

A 52-year-old woman with a history of two parturitions presented with lower abdominal pain. Multi-detector CT of the abdomen showed discontinuity of the sigmoid colon near the broad ligament on the left side. We assigned a provisional diagnosis of an internal hernia progressing through a defect in the broad ligament. SILS revealed a total broad ligament defect on the left side but no signs of ischemic, necrotic bowel. We successfully repaired the broad ligament defect with suturing. At the 2-month follow-up, the patient remained well with no signs of recurrence. This case appears to be the first report of a broad ligament hernia successfully diagnosed and repaired by SILS.

Strangulated small bowel obstruction in children

BACKGROUND

Diagnosing intestinal strangulation as a complication of small bowel obstruction (SBO) remains a considerable challenge in children. We evaluated the clinicoradiological parameters for predicting the presence of a strangulated intestine.

METHODS

We reviewed the medical records of 69 pediatric patients who underwent operation for acute SBO. Regression analysis was used to identify the parameters for predicting strangulated SBO.

RESULTS

Of the 69 patients with SBO, 27 patients had intestinal strangulation and were awarded one point each towards the overall clinical score: intractable continuous abdominal pain, tachycardia, white blood cell count >13,600/mm³, and abdominal distention. Patients with a clinical score ≥2 combined with the presence of ascites in ultrasound (US) results or with wall thickness and reduced wall contrast enhancement in abdominal computed tomography (CT) scans showed strong evidence for intestinal strangulation.

CONCLUSION

The combination of two or more clinical parameters, including intractable continuous abdominal pain, tachycardia, leukocytosis, and abdominal distention with the presence of ascites in US or wall thickness and reduced wall contrast enhancement in, is useful for the identification of strangulated SBO.

THE TYPE OF STUDY AND LEVEL OF EVIDENCE

Prognosis study; Level III.

Bowel Obstruction and Peritoneal Dialysis: A Case Report of a Patient with Complications from a Broad Ligament Hernia

Abdominal hernias are a common cause of bowel obstruction. The major types of abdominal hernias are external or abdominal wall hernias, which occur at areas of congenital or acquired weakness in the abdominal wall. An alternative entity is internal hernias, which are characterized by a protrusion of viscera through the peritoneum or mesentery. We herein present the case of a female peritoneal dialysis patient with bowel obstruction due to an internal hernia. Although an initial work-up did not lead to a correct diagnosis, an exploratory laparotomy revealed that she had intestinal herniation due to a defect in the broad ligament of the uterus, which was promptly corrected by surgery. The concerns about the perioperative dialytic management as well as the diagnostic problems regarding the disease that arose in our experience with the present patient are also discussed.

Broad ligament hernia successfully treated by laparoscopy: Case report and review of literature

We report a case of a 36-year-old woman with a history of caesarean section who presented with small bowel obstruction. Abdominal multi-detector CT showed discontinuity of the small bowel near the broad ligament on the left. We made a provisional diagnosis of an internal hernia through a defect in the broad ligament and performed laparoscopic exploration, which revealed a viable ileal loop incarcerated by the broad ligament. Multi-detector CT may be useful for diagnosing this type of defect preoperatively, whereby open surgery can be avoided.

The complicated Allen-Masters syndrome: small bowel herniation through a broad ligament defect

Small bowel obstruction through a broad ligament defect is a very rare condition. We present 2 cases, one without any associated abdominal trauma. Rapid diagnosis and treatment of this rare condition is of paramount importance.

Internal hernia of the broad ligament: CT diagnosis for laparoscopic management

One per cent of cases of mechanical occlusion of the small intestine are caused by internal hernias, the rarest type being an internal hernia through the broad ligament of the uterus, and representing approximately 5% of cases. While "conventional" treatment of mechanical occlusions of the small intestine is based on laparotomy, a laparoscopic approach is feasible in nearly half of cases, with an acceptable rate of morbidity. Preoperative diagnosis has for a long time been difficult but the usefulness has recently been emphasized of computed tomography. We report the cases of two patients who presented an internal hernia of the right broad ligament diagnosed with CT who afterwards underwent laparoscopic surgery.

Laparoscopic management of internal hernia of small intestine through a broad ligament defect

Internal herniation through a defect in the broad ligament is a rare condition. A 42-year-old multiparous woman presented with a long-standing history of right-sided abdominal pain. Laparoscopy revealed herniation of small bowel through a defect in the right broad ligament. The hernia was reduced, and the defect was corrected laparoscopically. The postoperative recovery was uneventful, and the previously persistent abdominal pain has resolved.

Elective plug repair of an incarcerated obturator hernia by the thigh approach after noninvasive manual reduction: report of two cases

An obturator hernia is a rare type of pelvic hernia, which can cause bowel obstruction. Despite improved imaging techniques, which can allow us to make a preoperative diagnosis, emergency laparotomy is still often carried out. We repaired this hernia electively in two elderly women by inserting a plug into the obturator canal via the thigh, after noninvasive manual reduction. Both patients were brought to our Emergency Department after the sudden onset of severe pain in the thigh or groin. The diagnosis was confirmed by computed tomography, and manual reduction was performed immediately thereafter. Since both patients had undergone groin hernia surgery of the identical side before, less-invasive inguinal or extraperitoneal approaches were considered impossible, but laparotomy seemed too invasive. Despite being an unfamiliar field for general surgeons, the thigh approach gives excellent and easy access to the obturator canal. The technique we describe is especially useful for patients who have undergone previous groin hernia operations. We expect that this method will become a standard technique for obturator hernias without strangulation.

Laparoscopic management of recurrent adhesive small-bowel obstruction: Long-term follow-up

PURPOSE

To evaluate the efficiency, safety, and outcome of laparoscopic adhesiolysis for recurrent small-bowel obstruction (SBO), when performed early after failed conservative treatment.

METHODS

Between 1999 and 2005, elective laparoscopic adhesiolysis was attempted in 46 patients with recurrent SBO after abdominal or pelvic surgery. Laparoscopic adhesiolysis was done during the acute onset of SBO after the patient failed to respond to 24 h of conservative treatment.

RESULTS

Fifteen patients (32.6%) presented with recurrent SBO and 31 patients (67.4%) presented with recurrent SBO and chronic abdominal pain. Postoperative adhesions were identified laparoscopically in all patients: as isolated bands in 11 patients, enteroperitoneal angulation in 12 patients, entero-enteral angulation in 17 patients, and extensive dense and matted intra-abdominal adhesions in 6 patients. Successful complete laparoscopic adhesiolysis was achieved in 42 of the 46 patients (91.3%). Conversion to minilaparotomy was required for a convoluted mass of adherent bowel in one patient (2.2%) and laparotomy was required for extensive dense and matted adhesions in three patients (6.5%). The mean follow-up was 46.5 months (range 24-89 months). Forty-three patients (93.5%) were asymptomatic after the operation. Only one patient (2.2%) had a further two episodes of SBO over 38 months of follow-up.

CONCLUSION

Laparoscopic intervention, when done early after the onset of symptoms, is highly feasible, safe, and effective in selected patients with recurrent SBO caused by postoperative adhesion.

Clinical spectrum of internal hernia: a surgical emergency

PURPOSE

To define the indicators of bowel ischemia caused by congenital or acquired internal hernia, based on our 10-year experience in one center.

METHODS

We reviewed the medical records, imaging studies, and operative findings of 20 patients who underwent surgery for an internal hernia at our medical center between 1995 and 2005. The clinical characteristics and related indicators of the patients with, and those without bowel ischemia were compared and analyzed statistically.

RESULTS

The subtypes of congenital internal hernia (CIH) included transmesenteric (n = 6, 60%), paraduodenal (n = 2, 20%), and pericecal (n = 2, 20%) hernia. The abdominal surgical procedures preceding acquired internal hernia (AIH) were Roux-en-Y anastomosis (n = 6, 60%) and appendectomy (n = 3, 30%). Transmesenteric hernia was the most prevalent type of CIH in children. Abdominal rebound tenderness, advanced leukocytosis (>18 000/mm(3)), or a high level of manual band form (>6%) were the positive predictive factors for bowel ischemia, whereas a history of chronic intermittent abdominal pain was a negative indicator. No recurrence was noted during the 10-year study period. The overall mortality rate was 20%, attributable to enteral bacteria sepsis in all cases.

CONCLUSION

Internal hernia is a rare but lethal condition. Early diagnosis and prompt surgical intervention provide the only chance of a successful outcome.