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

Quain hernia - A rare cause of acute small bowel obstruction. A case report and an updated literature review

Introduction and importance

Internal herniae are a rare cause of acute small bowel obstruction (SBO), accounting for <1% of all causes of SBO. Given their low incidence and often vague presenting symptoms there can be a delay in their diagnosis - which can lead to unnecessary morbidity for patients.

Case presentation

We present a case of a 34 year-old nulliparous female who presented with acute abdominal pain and transpired to have a closed loop obstruction of her ileum through a congenital defect in her broad ligament, or a Quain hernia.

Discussion

This paper will describe this case and provide an updated literature review of Quain herniae from recent research. With regards to surgical management of these hernia, both laparoscopic and open approaches are appropriate as long as appropriately trained surgical staff are involved. If a contraltateral defect in the Broad ligament is identified, this should be repaired prophylactically at the time in order to prevent future instances of internal herniation.

Conclusion

Increased awareness of the potential presenting symptoms and radiological features of Quain hernia, as outlined in this paper, is vital in order to reduce patient morbidity and mortality.

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Quain hernia is a subtype of internal hernia caused by a defect in the broad ligament.

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Their lack of recognition often leads to a delayed diagnosis and increased patient morbidity.

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Both open and laparoscopic repair are suitable in appropriately trained individuals.

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Contralateral defects should be fixed prophylactically to prevent future herniation.

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.

Prevalence of Endometriosis and Peritoneal Pockets in Women with Infertility and/or Pelvic Pain

OBJECTIVE

To evaluate the prevalence of endometriosis and peritoneal pockets and to analyze whether these pockets are associated with pain.

METHODS

Analysis of prospectively registered data of all women undergoing laparoscopy for infertility or pelvic pain between 1988 and 2011 at KU Leuven University Hospital.

RESULTS

Of 4497 women, 191 had 238 pockets, with a prevalence of 4.7% in women with infertility only, 4.9% in women with infertility and pelvic pain, and 3.5% in women with pelvic pain only (P = 0.045 for all infertility vs. pelvic pain only). Prevalence did not vary by age. Pockets were associated with endometriosis (P < 0.0001), which was found in 77% of women with pockets. Among women with infertility only, the prevalence of endometriosis was higher in women with pockets (P = 0.0001) than in women without. The prevalence of endometriosis was similar in women with infertility and pelvic pain or pelvic pain only. Pelvic pain as an indication for surgery was associated simultaneously (through logistic regression) with endometriosis (P < 0.0001) and pockets (P = 0.040). Pelvic pain severity was associated simultaneously with pockets (P = 0.0026) and the severity of subtle (P = 0.001), typical (P = 0.030), cystic ovarian (P = 0.051), and deep endometriosis (P < 0.0001). Pelvic pain severity was not associated with endometriosis in the pockets or the diameter or location of pockets.

CONCLUSIONS

The prevalence of pockets was low, at between 3.5% and 5%. Women with infertility only and pockets had more endometriosis than women without. Severe pelvic pain and pelvic pain as an indication for surgery were associated with the presence of pockets as well as the presence and severity of endometriosis.

Peritoneal Dialysis and Retroperitoneal Laparoscopic Radical Nephrectomy: A Favorable Experience With a Patient Complicated by Renal Cell Carcinoma

Peritoneal dialysis (PD) is an accepted modality for managing end-stage kidney disease. We herein report a 75-year-old female patient on chronic PD who was complicated by renal cell carcinoma. She was successfully treated with retroperitoneal laparoscopic radical nephrectomy followed by a prompt resumption of the procedure. Various surgeries disturbing the abdominal wall integrity often disrupt the regular PD schedule, and using minimally invasive approaches is therefore an attractive therapeutic option. Our experience emphasizes the feasibility and safety of a retroperitoneal approach–based laparoscopic technique based on several empirical examples. However, systemic studies on this topic are obviously lacking, so we strongly recommend the accumulation of more cases similar to our own. Several surgical concerns that need to be dealt with among PD patients are also discussed.

Pleuroperitoneal Communication and Ovarian Cancer Complicating Peritoneal Dialysis: A Case Report of a Patient with End-Stage Kidney Disease

Peritoneal dialysis has been a widely accepted modality for treating end-stage kidney disease, but a regular dialysis schedule can be seriously disrupted by various comorbid conditions requiring surgical intervention. A 40-year-old woman who had been receiving peritoneal dialysis was sequentially but separately complicated by pleuroperitoneal communication and ovarian cancer. Despite the need for temporary interruption of her peritoneal dialysis schedule, it was successfully resumed after the relevant surgeries for each disease. Several concerns regarding overall postoperative dialytic management strategies, including how to deal with the peritoneal dialysis catheter during the postoperative period as well as how long peritoneal dialysis should be interrupted, which remain an unresolved issue in the field of nephrology, are also discussed.