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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 57-59

A rare case of small-bowel obstruction due to broad ligament herniation


Department of General Surgery, Apollo BGS Hospitals, Mysore, Karnataka, India

Date of Web Publication26-Nov-2019

Correspondence Address:
Dilip Rajasekharan
Department of General Surgery, Apollo BGS Hospitals, Adichunchanagiri Road, Kuvempu Nagara, Mysore - 570 023, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_14_18

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  Abstract 


Small-bowel obstruction is a common cause of acute abdomen throughout the world. Internal hernia as the cause of small-bowel obstruction is exceedingly rare and accounts for only about 1% of all acute obstructions. Of this, a very small fraction may occur through defects in the broad ligament, whether congenital or iatrogenic. The symptomatology is consistent with that of small-bowel obstruction due to any other cause rendering preoperative diagnosis extremely difficult. Most cases are recognized intraoperatively. The complications are dreaded, as bowel gangrene and perforation secondary to prolonged herniation are well documented. A high index of suspicion is, thus, needed. In this case report, we present a patient of jejunal loop herniation into broad ligament who presented with acute intestinal obstruction.

Keywords: Broad ligament, jejunal loop herniation, small bowel obstruction


How to cite this article:
Rajasekharan D, Shanthakumar D, Subbarayappa S, Nagaraja JB. A rare case of small-bowel obstruction due to broad ligament herniation. Indian J Colo-Rectal Surg 2018;1:57-9

How to cite this URL:
Rajasekharan D, Shanthakumar D, Subbarayappa S, Nagaraja JB. A rare case of small-bowel obstruction due to broad ligament herniation. Indian J Colo-Rectal Surg [serial online] 2018 [cited 2019 Dec 11];1:57-9. Available from: http://www.ijcrsonweb.org/text.asp?2018/1/2/57/271747




  Introduction Top


Small-bowel obstruction is a common cause of acute abdomen. According to incidence, the most common causes of mechanical obstruction of small bowel include adhesions, tumors, and herniae. Internal hernia as the cause of small-bowel obstruction is exceedingly rare and accounts for about 1% of all acute obstructions.[1] Of this internal herniation through defects in the broad ligament, either congenital or iatrogenic is very rare.[2] It was first reported in 1861 as an autopsy finding.[3] There are <70 cases reported in literature.[4] The patient's symptoms are same as that of small-bowel obstruction. It is seldom diagnosed preoperatively, with most cases recognized intraoperatively. In this case report, we present a case of jejunal loop herniation into broad ligament presenting as acute intestinal obstruction.


  Case Report Top


History and examination

A 43-year-old female presented with a history of diffuse abdominal pain and bilious vomiting for 4 days. There was no history of constipation, diarrhea, or fever. The patient had a history of cesarean section 19 years ago and appendectomy 15 years ago. On examination, the patient was tachycardic and had mildly distended abdomen with diffuse tenderness. The scars of previous surgeries were noted. There was no guarding or rigidity. Erect X-ray abdomen suggested small-bowel obstruction. After initial resuscitation, a trial of conservative management was attempted. The patient failed to respond to conservative therapy. Contrast-enhanced computed tomography (CECT) abdomen showed intestinal obstruction with dilated small-bowel loops, the zone of transition being at distal jejunal/proximal ileal level in the pelvis, and minimal ascites. After optimization with fluids and antibiotics, she was taken for exploratory laparotomy.

Operative course

On laparotomy, dilated jejunal bowel loops with collapsed ileal loops were noted. There was a left-sided broad ligament herniation of terminal jejunal loop [Figure 1] and [Figure 2] through a 3 cm × 4 cm defect [Figure 3] which appeared to be congested and obstructed. A hemorrhagic cyst in the right ovary was also noted. Adhesiolysis was performed. The obstruction was released. The bowel was found to be viable and hence was preserved. The rent in the broad ligament was repaired using 3-0 Vicryl sutures. The hemorrhagic cyst was excised, and after a thorough lavage, the abdomen was closed.
Figure 1: Intraoperative image of broad ligament and jejunal loop

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Figure 2: Broad ligament herniation of terminal jejunal loop

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Figure 3: Rent in the broad ligament

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Postoperative course

Postoperatively, the patient was observed in the intensive care unit for a day. She was managed with antibiotics, analgesics, intravenous fluids, and other supportive measures. She was started orally on postoperative day 1 and stepped up. The patient tolerated the treatment well and was discharged on postoperative day 4. On follow-up after 1 week, the patient is comfortable, asymptomatic, and leading a normal life.


  Discussion Top


The most common causes of small-bowel obstruction include adhesive obstruction, compression due to tumors, and obstructed inguinal or femoral herniae.[4],[5],[6] Internal hernia is one of the rare causes of small-intestinal obstruction. Among internal herniae, paraduodenal and those occurring through the foramen of Winslow rank highest. Internal hernia through defect in the broad ligament is extremely rare.[4],[7]

Internal herniae are broadly classified into two types: those that occur through an opening in the peritoneal fold and those that occur through a defect in the mesentery or omentum.[4],[8] Broad ligament herniation may be congenital or acquired with congenital causes having an embryological basis leading to a developmental defect in the supports of uterus and acquired causes following previous insults to the abdomen or iatrogenic.[1] Another classification based on the anatomical position with Type I defect caudal to the round ligament, Type II defect above the broad ligament, and Type III between the round and broad ligaments.[1] They have also been described as fenestra type (involving both leaves of the broad ligament) and pouch type (where either anterior or posterior leaf is involved).[2],[9]

Preoperative diagnosis of this condition is difficult in spite of the advances in imaging technology. CECT scan is the imaging modality of choice.[10] Most cases are still diagnosed intraoperatively. The onus, thus, lies on the surgeon to have a high index of suspicion. The complications such as bowel gangrene and perforation secondary to prolonged herniation are well documented.[4],[11],[12]

There are several reasons for a broad ligament defect, which include operative trauma, prior pelvic inflammatory disease, birth trauma during delivery, and congenital abnormalities.[1],[4],[6] As the patient in this case had previous cesarean section and appendectomy, it stands to reason that operative trauma might have been the cause of broad ligament hernia.[4]


  Conclusion Top


Although small-bowel obstruction due to small-bowel herniation into broad ligament is uncommon, it may develop into a life-threatening condition if not recognized early on. Early diagnosis and treatment is essential. A high index of suspicion has to be maintained regarding rarer sites of obstruction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kanbur AS, Ahmed K, Bux B, Hande T. Jejunal obstruction and perforation resulting from herniation through broad ligament. J Postgrad Med 2000;46:189-90.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Gupta N, Boler L, Blankstein J. Bowel herniation through broad ligament mimicking ovarian torsion: A novel presentation. J Clin Gynecol Obstet 2013;2:93-5.  Back to cited text no. 2
    
3.
Baron A. Defect in the broad ligament and its association with intestinal strangulation. Br J Surg 1948;36:91-4.  Back to cited text no. 3
    
4.
Lu HF, Chang DY, Chen MJ, Chen SU, Ho HN, Yang YS. Internal herniation through a defect in the broad ligament of the uterus. Taiwan J Obstet Gynaecol 2005;44:273-5.  Back to cited text no. 4
    
5.
Livaudais W Jr., Hartong JM, Otterson WN. Small bowel herniation through a defect in the broad ligament. Am J Obstet Gynecol 1979;133:927-8.  Back to cited text no. 5
    
6.
Simstein NL. Internal herniation through a defect in the broad ligament. Am Surg 1987;53:258-9.  Back to cited text no. 6
    
7.
Cleator IG, Bowden WM. Bowel herniation through a defect of the broad ligament. Br J Surg 1972;59:151-3.  Back to cited text no. 7
    
8.
Bertelsen S, Christiansen J. Internal hernia through mesenteric and mesocolic defects. A review of the literature and a report of two cases. Acta Chir Scand 1967;133:426-8.  Back to cited text no. 8
    
9.
Hiraiwa K, Morozumi K, Miyazaki H, Sotome K, Furukawa A, Nakamaru M. Strangulated hernia through a defect of the broad ligament and mobile cecum: A case report. World J Gastroenterol 2006;12:1479-80.  Back to cited text no. 9
    
10.
Suzuki M, Takashima T, Funaki H, Uogishi M, Isobe T, Kanno S, et al. Radiologic imaging of herniation of the small bowel through a defect in the broad ligament. Gastrointest Radiol 1986;11:102-4.  Back to cited text no. 10
    
11.
Armstrong CP, Drummond A. Small bowel obstruction and perforation through a defect in the broad ligament. J R Coll Surg Edinb 1983;28:333-4.  Back to cited text no. 11
    
12.
Ishihara H, Terahara M, Kigawa J, Terakawa N. Strangulated herniation through a defect of the broad ligament of the uterus. Gynecol Obstet Invest 1993;35:187-9.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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