Rare Contents of an Internal Hernia through a Defect of the Broad Ligament of the Uterus

Inflamed Appendix Protruding Through a Right Broad Ligament Defect: A Case Report

The protrusion of the appendix through a broad ligament defect suggests an extremely rare clinical entity, especially when the clinical manifestation of this condition is acute appendicitis. The current article presents a case of a 23-year-old female who presented to the emergency department with right lower abdominal pain and nausea, accompanied by elevated white blood cell count. Imaging performed, both ultrasound and computed tomography, reported acute appendicitis, without evidence of a broad ligament defect. During exploratory laparoscopy, the defect was identified, the appendix was retrieved and ligated and sutures were applied to the defect. The postoperative course of treatment was uneventful, and pathology confirmed inflammation of the appendix and also revealed a small neuroendocrine tumor. The value of emergency laparoscopy for the diagnosis of this rare condition and the therapeutic management which involves the closure of the defect to prevent future internal hernia are issues highlighted in this article.

Case report: Emergency management of unilateral herniation of bowel and a bilateral defect of the broad ligament in a resource limited setting

INTRODUCTION

Broad ligament herniation is a rare type of internal hernia, presenting as a diagnostic challenge. An exploratory laparotomy can be performed to definitively diagnose and treat the defect.

CASE PRESENTATION

A 36-year-old female, with no known comorbids and no significant past medical and surgical history presented with acute abdominal pain, multiple episodes of vomiting, and absolute constipation. After clinical and radiologic investigations, the diagnosis of an internal herniation of small bowel to the broad ligament was suspected. An emergent exploratory laparotomy was then performed. Intra-operatively it was found that she had a bilateral defect to the broad ligament and a unilateral broad ligament hernia (BLH). Postoperatively she remained vitally stable and was discharged home.

CLINICAL DISCUSSION

We report a rare case of a unilateral broad ligament hernia with a bilateral defect. Diagnosis of BLH is associated with diagnostic uncertainty mainly due to its rarity and nonspecific presentation.

CONCLUSION

Although broad ligament herniation is rare, it is a significant cause of intestinal obstruction and may result in complications if not attended to timely. Early diagnosis and management is necessary to minimize associated morbidity and mortality that can occur as a consequence of bowel ischemia and necrosis.

Lesser omental hernia through a defect in the posterior layer of the lesser omentum

BACKGROUND

In previously reported cases of lesser omental hernia, a rare clinical presentation, the herniated intestinal tract was passing through both peritoneal layers of the lesser omentum to herniate into the peritoneal cavity or bursa omentalis. Here we present a very rare case of lesser omentum hernia, where the transverse colon entered through only the posterior layer of the lesser omentum to form a hernia between the anterior and posterior layers.

CASE PRESENTATION

A 43-year-old man was admitted to the emergency department with acute abdominal pain. Plain abdominal computed tomography (CT) revealed a change in the caliber of the transverse colon between the stomach and pancreas, forming a closed loop on the cephaloventral side of the stomach. On contrast-enhanced CT images, vessels were observed in the contrast-enhanced lesser omentum surrounding the herniated intestine. The patient was diagnosed with a lesser omental hernia and underwent laparoscopic surgery. Intraoperatively, the transverse colon was covered by the anterior layer of the lesser omentum, and a defect was found in the posterior layer of the lesser omentum on the dorsal side of the stomach. A 2-cm incision was made in the posterior layer of the lesser omentum to widen the small defect. The herniated intestinal section was removed from the hernia sac, and the transverse colon was retained unresected. The postoperative course was uneventful.

CONCLUSIONS

As illustrated in this first case of a lesser omental hernia forming between the anterior and posterior layers, characteristic CT findings may play an active role in the diagnosis of this rare presentation.

Closed loop ileus caused by a defect in the broad ligament: A case report

BACKGROUND

Closed loop ileus caused by entrapment of bowel in a defect of the broad ligament is a rarity. Only a few cases have been reported in the literature.

CASE SUMMARY

We present the case of a 44-year-old, healthy patient with no prior history of abdominal surgery who developed a closed loop ileus due to an internal hernia secondary to a defect in the right broad ligament. She first presented to the emergency department with diarrhea and vomiting. As she had had no previous abdominal surgery, she was diagnosed with probable gastroenteritis and discharged. The patient subsequently returned to the emergency department due to a lack of improvement in her symptoms. Blood tests showed an elevated white blood cell count and a closed loop ileus was diagnosed on an abdominal computer tomography scan. Diagnostic laparoscopy revealed an internal hernia entrapped in a 2 cm large defect in the right broad ligament. The hernia was reduced and the ligament defect was closed using a running, barbed suture.

CONCLUSION

Bowel incarceration through an internal hernia may present with misleading symptoms and laparoscopy may reveal unexpected findings.