Broad ligament hernia: A rare condition causing small bowel obstruction

Abstract

Dear Editor, Small bowel obstruction (SBO) is a condition characterized by intraluminal flow blockage caused by several etiologies. Postlaparotomy adhesion, incarcerated hernia, and neoplasm are the top 3 causes of SBO. Internal herniation, though rare, accounts for approximately 1% of SBO. Broad ligament hernia is an even more unusual form of internal herniation, reported in 4%–5% of internal herniation cases. Here, we report a case of broad ligament herniation, leading to strangulated SBO. A 68-year-old multiparity woman without history of abdominal surgery presented to the emergency department with acute onset of lower abdominal pain. The pain was intermittent, colicky, located on the infraumbilical region, lasting for 6 hours before she sought medical attention, and did not respond to analgesics. At triage, vital signs were relatively stable, except blood pressure of 188/81 mm Hg. Physical examination showed tenderness over the left lower quadrant and hypoactive bowel sound. Hemogram, liver function, and renal function were within normal limits, except for a slightly elevated serum lactate level of 13.2 mg/dL. Supine kidney, ureter, and bladder radiograph showed a mildly dilated bowel loop. The initial impression was ileus, and she was kept on bowel rest with intravenous fluid repletion after an enema. After 24 hours of medical treatment, her symptoms persisted with several vomiting bouts. Muscle guarding over the left lower quadrant of abdomen was noted. Contrast-enhanced computed tomography showed disclosing diffuse loop dilatation of the small intestine with the transitional zone in the pelvic region and a moderate amount of ascites. Under the impression of SBO, she underwent emergent exploratory laparotomy. Internal herniation of the small intestine into a 3-cm defect in the left broad ligament was found, resulting in strangulation of the small bowel measured approximately 40 cm in length. The nonviable segment of the small intestine was resected and anastomosed via hand-sewn method. In addition, the defect of the left broad ligament was repaired, and the right-sided broad ligament was examined as well. The patient had an uneventful postoperative recovery and was discharged on postoperative day 9. There are several classification systems regarding broad ligament herniation, which is summarized in Supplementary Data, https://links.lww.com/FJSS/A4. Computed tomography is the imaging modality of choice. Mechanical SBO with double transitional zone, bowel loops herniated beside the uterus with slight deviation of uterus to the contralateral side, enlargement of the distance between the uterus and one of the ovaries, and presence of free fluid in the pelvis would lead to suspicion of broad ligament herniation.[1] A standard therapeutic intervention has not yet been established.[2] Diagnostic laparoscopy could be performed if the preoperative diagnosis is uncertain. Once the broad ligament defect with internal herniation has been found, it can be managed with the laparoscopic approach. However, laparoscopic surgery is contraindicated in the following situations: when the diameter of small bowel is greater than 4 cm, there is evidence of bowel ischemia, history of severe adhesion, or presence of inflammatory bowel disease.[3] In conclusion, broad ligament hernia should be considered one of the differential diagnoses in a multiparity woman without previous surgical history, presenting with SBO. Early diagnosis and timely surgical intervention may reduce the likelihood of morbidity and mortality.