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.
In 1955, Allen and Masters reported the first clinical case series of broad ligament tears. It was preceded by an autopsy report by Quain (1861) describing the first small bowel obstruction (SBO) by herniation through the broad ligament. SBO by internal herniation is extremely rare especially if being caused by a parametrium defect. Here, we report 2 cases with different etiologies.
Case Reports
The first case concerns a 34-year-old gravida 0, para 0 woman referred to our institution on her request after a 2-day period of conservatively treated ileus. She had no relevant medical history and presented with nausea, a generalized tender abdomen, and nasogastric tube in situ. A postintravenous contrast computed tomography scan of the abdomen showed an image in keeping with mechanical obstruction of the small bowel in the pelvis abutting the uterus. The bowel loops showed mucosal thickening, mild congestion, and enhancement and there was stranding of the perimesenteric fatty tissue. All these findings are indicative of an early stage of bowel ischemia ( Figure 1 ). A subumbilical midline laparotomy followed, which showed distended small bowel and a left-sided (type 2) herniation of few ileum loops through a 4-cm defect in the broad ligament ( Figure 2 ). The bowel appeared vital and the bilateral defects in the broad ligament were closed with running polyglactin sutures. The patient had a complete postoperative recovery.
The second case, a 45-year-old gravida 2, para 2 woman, presented with upper quadrant abdominal pain, nausea, and vomiting for 3 days after an acute start. A computed tomography scan of the abdomen showed mechanical obstruction of the small bowel in the pelvis just adjacent to the uterus. The following diagnostic laparoscopy revealed SBO by herniation (type 2) through a 2-cm broad ligament tear (type 2), extensive bowel distention, and reactive ascites. The bowel remained vital and the defect could be closed with running polyglactin sutures. The patient had an uneventful recovery.
Comment
Internal herniation of small bowel is a rare cause of SBO seen in 0.2-1% of all cases. Only 4-5% of these herniations are caused by a defect in the broad ligament making it extremely rare. Although the ileum is most commonly involved, herniation of colon, ovary, and ureter has also been described.
The causes can be divided into congenital and acquired. The most important congenital cause is a ruptured cyst in the broad ligament. The cyst is an embryological remnant of the müllerian tubes. Acquired causes include iatrogenic lesions, pelvic inflammatory disease, or traumatic lesions. In 80% of the cases multiparity is a predisposing factor.
Two different types can be identified according to Hunt’s classification. In the first type, only 1 layer of the bilayer ligament is involved, producing a free space in which the herniated structures become entrapped. The second type is most common and is a complete herniation through the ligament as in our cases.
A different classification can be made on the basis of anatomical location of the defect. Three hernia locations have been mentioned, the first occurring caudal to the round uterine ligament. The second type occurs cranial of the round ligament. The third type occurs through the mesoligamentum teres uteri and is positioned between the round and broad ligament. The defect is most often closed using absorbable sutures. However, others chose to cleave the defect (type 1) to prevent reincarceration or leave it in situ with no expected clinical consequences. No evidence exists if incidentally found defects should be closed routinely.
Laparoscopy has an additional value in the treatment of broad ligament defects in the absence of extensive bowel distention. It has been mentioned earlier as a very feasible resource in the management of bowel obstruction due to internal hernias. However, in line with the finding of Strickland et al, conversion to a laparotomy is frequent in case of inadequate visualization, as in our patients.
In conclusion, we present 2 cases of SBO through a broad ligament defect with typical and atypical antecedents. This report underscores the value of rapid diagnosis and treatment of symptomatic broad ligament defects especially in patients without prior surgery and after pregnancies.
The authors report no conflict of interest.
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