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

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.

Herniation of the broad ligament… And the other side?

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Internal hernia is a classical cause of small bowel obstruction but remains rare.

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Discuss the appropriate management of internal hernia.

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Broad ligament hernias account for less than 5% of internal hernia.

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When performing surgery for broad ligament hernia, consider looking for contralateral hernia.

Introduction

Broad ligament herniation is a very uncommon cause of small bowel obstruction. Surgery permits reduction of the hernia and closure of the defect to prevent recurrence.

Presentation of case

We report a rare case of a 35 year old woman admitted in our hospital for recurrence of a small-bowel obstruction, secondary to internal hernia. The patient underwent intestinal resection in 2018 for herniated left broad ligament of the uterus strangulated.

This time, the computed tomography revealed a double junctional syndrome with ileal dilation localized in right side of uterus. Emergency surgery confirmed internal hernia with passage of ileal loops through the right broad ligament. After reduction of the hernia, closure of the defect was performed to prevent recurrence. For the first time, a check of other classic abdominal hernias was carried out.

Discussion

Internal hernias are responsible for less than 5% of mechanical bowel obstruction. Broad ligament hernias represent only 4–7% of these hernias.

The diagnosis is often delayed, because of its rarity and lack of surgical history. Surgery confirms the diagnosis, treats the occlusion and prevents recurrence.

The presence of several internal hernias has never been studied and no recommendation has been made on this topic.

Conclusion

This case demonstrate the importance of a systematic exploration of other internal abdominal hernias during the surgery, especially a contralateral broad ligament hernia.

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.

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.

Hernia emergencies

Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles are constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. Mesh reinforcement provides the most durable long-term results. Underlay positioning is associated with the best outcomes. Components separation is a useful technique to achieve tension-free primary fascial reapproximation. The choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia emergencies, morbidity is high, and postoperative wound complications should be anticipated.

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.

Strangulated hernia through a defect in the broad ligament: a sheep in wolf's clothing

Small bowel obstruction due to an internal hernia is an uncommon finding and, when caused by a defect in the broad ligament, it is exceptionally rare. This condition should be considered when evaluating all female patients presenting with de novo small bowel obstruction. We report an unusual case of intestinal obstruction from an internal hernia through the left broad ligament in a middle-aged patient with no prior surgical history and discuss the relevant literature and treatment. Although an oncologic diagnosis should be entertained, a small bowel obstruction arising in the pelvis may involve the broad ligament in parous patients. An internal hernia through the broad ligament should be considered in the differential diagnoses of female patients presenting with intestinal obstruction.

Internal hernias: clinical findings, management, and outcomes in 49 nonbariatric cases

Internal hernia, the protrusion of a viscus through a peritoneal or mesenteric aperture, is a rare cause of small bowel obstruction. We report the clinical presentation, surgical management, and outcomes of one of the largest series of nonbariatric internal hernias. Ten-year retrospective review of patients at our institution yielded 49 cases of internal hernias. Majority of patients presented with symptoms of acute (75%) or intermittent (22%) small bowel obstruction. While 16% of CT scans were suspicious for internal hernia, in no cases the preoperative diagnosis of internal hernia was made. The most frequent internal hernias were transmesenteric (57.0%) and 34 hernias (69%) were caused by previous surgery. All internal hernias were reduced and the defects were repaired. Compromised bowel was present in 22 cases and 11 patients underwent small bowel resection. The mean postoperative hospitalization was 10.9 days. The overall mortality rate from our series is 2%, and the morbidity rate is 12%. Transmesenteric hernias, as complications of previous surgeries, are the most prevalent internal hernias. Preoperative diagnosis of internal hernia is extremely difficult because of the nonspecific clinical presentation. However, if discovered promptly, internal hernias can be repaired with acceptable morbidity and mortality.

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.