DEPARTMENT OF GENERAL SURGERY



   
 

A CASE OF STRANGULATED INTERNAL HERNIA INTO RIGHT BROAD LIGAMENT: CASE REPORT AND REVIEW OF LITERATURE

Basavaraj Karepagol, Zameerulla T, Nagaraj P

Department of General Surgery,

S S Institute of Medical Science and Reserch Center,

Davangere, Karnataka, India

basu3083@yahoo.co.in ,     mobile: +919916990310 

ABSTRACT

A 35 year old female patient presented with severe abdominal pain, vomiting and not passing stools for 2days. History of lower segment cesarean section 13years back with below umbilicus midline scar present. All blood investigations were normal, erect X - Ray abdomen was showing  step ladder type of air shadow in small bowel and ultrasound abdomen was inconclusive of intestinal obstruction. Patient put in conservative management, but patient was developing abdominal distension so we planned exploratory laparotomy.  Intra operatively we found internal hernia of proximal ileum into the anterior layer of right broad ligament. After release of neck of the sac around 10cm of ileum was discoloured and severe constricting rings were present on either side of the discoloured segment, hence  planned for resection and end to end anastomosis. Postoperative period was uneventful. Intestinal obstruction due to internal hernia into broad ligament is extremely rare condition. In conclusion, we emphasize internal hernia of broad ligament should be added to the list of differntial diagnosis for instestinal obstruction in female patients.

Key words: Internal hernia; broad ligament; intestinal obstruction.

Introduction

Intestinal obstruction due to internal hernia through broad ligament is extremely rare condition to occur. In literature very few reported cases are present. We are now presenting a case in which internal hernia occurred through right broad ligament which was diagnosed intraoperatively

Case Report

          A 35 year old female patient came to a casualty with abdominal pain, vomiting and not passing stools since 2 days. On examination patient was mildly dehydrated, per abdominal examination revealed abdomen was flat, guarding was present throughout the abdomen and bowel sounds were increased. History of para2 living2  and both deliveries were lower segment cesarean section, last child birth was 13years back. There was a midline scar extending from umbilicus to pubic symphysis. Emergency X – Ray erect abdomen and all routine blood investigations were done. Erect X – Ray was showing typical step ladder type air shadow in small bowel with no air in cecum(figure1). Ultrasound abdomen was done and the report was not conclusive of intestinal obstruction. So for time being we considered conservative management with Ryle’s tube aspiration, and we kept the patient nil by mouth. Abdominal pain decreased but patient complained of abdominal distension and not passing flatus and stool. So we planned for emergency exploratory laparotomy, abdomen opened with mid mid-line incision, there was dense adhesions between uterus and the peritoneum. After careful exploration we found herniation of proximal ileum loop into the anterior layer of right broad ligament(figure2, 3). Neck of sac opened and the bowel released which was found discolored. There was defect of size 2x2 cm in anterior layer of right broad ligament which was sutured with 2-0 vicryl. Around 10 cm of ileum was discolored and severe constricting rings were present on either side of the discolored segment, so resection of that segment of bowel done and end to end anastomosis done in 2 layers with 3-0 vicryl and 3-0 silk(figure4). Complete haemostasis obtained and right flank drain kept. Abdomen sutured in layers. Postoperative period was uneventful and patient recovered well.

Discussion

 Intestinal obstruction remains one of the most common intra-abdominal problems faced by general surgeons in their practice. Whether caused by hernia, neoplasm, adhesions, or related to biochemical disturbances, intestinal obstruction of either the small or large bowel continues to be a major cause of morbidity and mortality. Hernia (10 – 20%) is second most common cause after adhesions (60%) in intestinal obstruction; in that obstruction caused by internal henia is still rare (5 – 7%). Various types of internal hernia are 1. Paraduodenal(Lt.>Rt.) - 53%, 2. Foramen of Winslow - 8%,  3. Transmesenteric - 8%, 4. Transomental - 1-4%, 5. Pericaecal - 13%,  6. Intersigmoid - 6%,7. Supravesical and pelvic - 6% Pelvic hernias include hernias through Broad ligament (4 - 5%), perirectal fossa & fossa of Douglas5,6,7. In literature very few reported cases of intestinal hernia through broad ligament were present. Usually the ileum is involved, although a rare case of herniation of the colon has been reported.8 Most herniations occur with the fenestra-type defect, with only 3 of 57 cases reported in Japan being attributed to the pouch-type defect.9 Also, the length of the herniated loop (up to 100 cm reported) is greater through a fenestra-type defect than through a pouch-type defect. Herniation can occur either from anterior to posterior or in the opposite direction, and the herniated loop can displace the uterus to the contralateral side.

 

Anatomic defects of broad ligament;

Anatomic defects of the broad ligament can be either congenital (as a result of a developmental defect) or acquired. Several factors have been attributed to causing these defects, including trauma during pregnancy or delivery, pelvic inflammatory disease, and surgical damage. Congenital cystic structures have been described within the broad ligament as remnants of the mesonephric or Müllerian ducts. When these cysts rupture, they have been hypothesized to leave behind a defect in the broad ligament. Spontaneous rupture of these cysts could account for defects in patients who are nulliparous, have never undergone a pelvic surgical procedure, or have never had pelvic inflammatory disease. Operative, birth, or pregnancy traumas may also induce such a defect in the broad ligament by rupturing the cystic embryologic remnants.1

Although most commonly unilateral, the defect can occur bilaterally. Hunt classified broad ligament defects into 2 types2 :

  • The fenestra type: The defect involves both the anterior leaf and the posterior leaf of the broad ligament, creating an open window anteriorly to posteriorly.
  • The pouch type: The defect involves only 1 layer, either the anterior leaf or the posterior leaf of the broad ligament.

Cilley et al proposed another classification depending on the anatomic location of the defect.3

  • Type I defects are by far the most frequent and occur through the whole broad ligament.
  • Type II defects occur through the mesosalpinx and the mesovarium.
  • Type III defects occur through the mesoligamentum teres.

Fafet et al later added a fourth type, in which the defect involves only the mesosalpinx.4

In my case defect is pouch type (anterior layer of Right broad ligament), which is very rare to occur.

References

1.     Guillem P, Cordonnier C, Bounoua F, Adams P, Duval G. Small bowel incarceration in a broad ligament defect. Surg Endosc. Jan 2003;17(1):161-2. [Medline].

2.     Hunt AB. Fenestra and pouches in the broad ligament as an actual and potential cause of strangulated intraabdominal hernia. Surg Gynecol Obstet. 1934;58:906-13.

3.     Cilley R, Poterack K, Lemmer J, Dafoe D. Defects of the broad ligament of the uterus. Am J Gastroenterol. May 1986;81(5):389-91. [Medline].

4.     Fafet P, Souiri M, Ould Said H, Mattei M, Godlewski G. [Internal hernia of the small intestine through a breach of the broad ligament, apropos of a case. Review of the literature]. J Chir (Paris). Jun-Jul 1995;132(6-7):314-7. [Medline].

5.     Karaharju E, Hakkiluoto A. Strangulation of small intestine in an opening of the broad ligament. Int Surg. Aug 1975;60(8):430. [Medline].

6.     Cleator IG, Bowden WM. Bowel herniation through a defect of the broad ligament. Br J Surg. Feb 1972;59(2):151-3. [Medline].

7.     Ghahremani GG. Internal abdominal hernias. Surg Clin North Am. Apr 1984;64(2):393-406. [Medline].

8.     Rabushka SE. Colon hernia through a hiatus in the broad ligament. Report of a case and review of the literature. Obstet Gynecol. Feb 1968;31(2):261-5. [Medline].

9.     Terado M, Okazaki M, Shinozaki K. A case report of internal herniation through an abnormal defect in the broad ligament. Shujutsu. 2002;56:265-9.

10. Haku T, Daidouji K, Kawamura H, Matsuzaki M. Internal herniation through a defect of the broad ligament of the uterus. Abdom Imaging. Mar-Apr 2004;29(2):161-3. [Medline].

 

 

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