Internal Herniation of Adnexa Through a Defect of the Broad Ligament: Case Report and Literature Review

Bilateral tubal incarceration into the broad ligaments caused by pelvic endometriosis: A case report

Introduction:

Endometriosis is characterised by the presence of functional endometrial tissue outside the uterus. Salpinges are a common location of endometriotic implants. Endometriosis located into the broad ligament is a rare event.

Case description:

A 38-year-old infertile woman presented to our attention with moderate left iliac fossa pain after menses and intermenstrual bleeding. Transvaginal ultrasounds and pelvic magnetic resonance evidenced the presence of bilateral haematosalpinges. At the laparoscopic pelvic exploration, fallopian tubes were absent. Opening and dissecting the apical portion of the broad ligaments, we identified bilateral haematosalpinges incarcerated in the homolateral broad ligaments. We performed bilateral salpingectomy. Histological examination confirmed the presence of endometriosis.

Conclusion:

Care must be taken to the diagnostic assessment, counselling about the surgical programme before the intervention especially in patients during the reproductive period when the possibility of ablative surgery and subsequent need for an assisted reproductive technique exists.

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.

Broad ligament hernia: Two contrasting ways to a common goal - Two case reports with review of literature

Introduction

Broad ligament hernia (BLH) is a rare but potentially life threatening condition. One of the two cases described here is the only reported case of BLH in recent literature, where marsupialisation was done. These two case reports comprise the only reported side by side pictorial comparison of the two laparoscopic surgical therapeutic options for BLH.

Presentation of cases

Both patients presented with classical symptoms and signs of acute intestinal obstruction. Imaging confirmed obstructed left BLH in case 2 and indicated a complete small bowel obstruction in case 1. Both cases were successfully managed laparoscopically. Both patients had an uneventful immediate postoperative recovery and have not had recurrence over a mean follow up period of 34.5 months.

Discussion

BLH is rare among all types of internal herniae. It accounts for only 4% of internal herniae and is a difficult condition to diagnose. The advent of computed tomography has increased chances of accurate preoperative diagnosis.

Conclusion

BLH can be successfully managed by minimally invasive surgery, even in the acute setting. When tightly entrapped bowel is unyielding; it is better not to risk injury to it by aggressive attempts at its reduction. It is safer to attempt widening of the defect into which it is entrapped, whenever feasible.

•

Internal herniae are a rare cause of acute bowel obstruction

•

Among internal herniae, broad ligament hernia is even more uncommon

•

One of the two cases described in this paper is the only reported case of BLH in literature, where marsupialization was done

•

This is the only paper with a pictorial comparison of the two contrasting ways in which this condition can be treated

Strangulated internal hernia due to defect in broad ligament: a case report

Small bowel obstruction is a relatively common disease process accounting for up to 16 percent of surgical admissions and more than 300,000 operations annually in the United States. Approximately 5–8 percent of small bowel obstructions can be attributed to internal hernias. A slightly lower percentage, roughly 4–7 percent, of these internal hernias are noted to originate from a defect in the broad ligament of the uterus. A majority of broad ligaments defects causing a small bowel obstruction are not diagnosed preoperatively due to the equivocal imaging findings as well as the infrequency of this etiology. To date, there are very few case reports describing this disease process. This case report describes a 70-year-old female who was found to have a defect in her broad ligament causing a small bowel obstruction leading to subsequent strangulated bowel.

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.

Adnexal Incarceration in a Posterior Pelvic Peritoneal Defect Mimics Ovarian Torsion

Surgery for suspected ovarian torsion sometimes reveals unexpected sources of pelvic pain, such as internal hernias, adhesions, or anatomic defects. A 23-year-old nulligravida with Alagille syndrome was taken to the operating room with suspected ovarian torsion. Intraoperatively, the right adnexa bulged out of a right-sided, posterior peritoneal cleft that incarcerated most of the enlarged ovary. No ovarian torsion was identified. The left adnexa appeared to be normal; however, it dwelled within a left-sided posterior peritoneal cleft. The bilateral posterior peritoneal defects that housed the adnexa were likely of congenital etiology. Although adnexal incarceration is a rare finding at surgery for suspected ovarian torsion, it should be part of the differential diagnosis when evaluating acute pelvic pain.

Case Report of an Internal Hernia through a Unilateral Congenital Defect of the Broad Ligament and Literature Review

We report a case of small bowel obstruction resulting from the herniation of small bowel through a unilateral defect in the broad ligament of a woman who had no prior abdominal surgery and was nulliparous. In the absence of previous uterine surgery, delivery trauma and pelvic pathology, congenital abnormality should be considered the cause of the defect in the broad ligament.

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.

Unexpected findings at diagnostic laparoscopy: caecal incarceration with concurrent appendicitis in a patient with bilateral broad ligament defects

Internal herniations through broad ligament defects are very rare. We present the first report of the triad of broad ligament defect, internal herniation of the caecum and appendicitis. A 36-year-old woman with phocomelia presented with right iliac fossa pain and vomiting. The patient had no previous history of trauma or surgery. Abdominal ultrasound showed a small amount of free fluid. At laparoscopy, bilateral broad ligament defects were found, with herniation of the caecum and an inflamed appendix through the right-sided defect. A laparoscopic salpingo-oophorectomy was required for reduction of the herniated bowel, and an appendicectomy was performed. Broad ligament defects may be congenital or acquired. In this case, in light of the limb abnormality and absence of previous surgery, a congenital aetiology is more likely. Ultrasound scan is not reliable and, although computed tomography may be of help, a diagnostic laparoscopy is the best investigation.