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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Broad ligament hernia successfully treated by laparoscopy: Case report and review of literature Masatoshi Matsunami, Hiroshi Kusanagi, Ken Hayashi, Shigetoshi Yamada & Nobuyasu Kano Department of Surgery, Kameda Medical Center, Chiba, Japan
Keywords Broad ligament hernia; laparoscopy; small bowel obstruction Correspondence Masatoshi Matsunami, Department of Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba 296–8602, Japan. Tel: 04 7092 2243 Email: [email protected]
Abstract We report a case of a 36-year-old woman with a history of caesarean section who presented with small bowel obstruction. Abdominal multi-detector CT showed discontinuity of the small bowel near the broad ligament on the left. We made a provisional diagnosis of an internal hernia through a defect in the broad ligament and performed laparoscopic exploration, which revealed a viable ileal loop incarcerated by the broad ligament. Multi-detector CT may be useful for diagnosing this type of defect preoperatively, whereby open surgery can be avoided.
Received 22 February 2014; accepted 11 May 2014 DOI:10.1111/ases.12119
Introduction According to a report by Baron (1), intestinal strangulation due to a broad ligament was initially reported by Quain in 1861. Internal hernia as a cause of small bowel obstruction (SBO) accounts for only 1% of all intestinal obstructions. Broad ligament internal hernia is extremely rare and constitutes 4% of all internal hernias (2). Laparoscopy is not usually recommended for SBO because of the difficulty in identifying the point of obstruction. However, once a hernia caused by the broad ligament has been diagnosed, we believe that the laparoscopic approach is better than an open procedure. We report a case of SBO diagnosed preoperatively and managed successfully by laparoscopic surgery.
Case Presentation A 36-year-old woman with a history of caesarean section was admitted to our hospital with lower abdominal pain and vomiting. The patient was afebrile and her vital signs were within normal limits. Physical examination disclosed a mildly distended abdomen with diffuse severe tenderness but no peritoneal signs. Laboratory findings were not suggestive of inflammation. Abdominal multi-
detector CT showed discontinuity of the small bowel near the left broad ligament (Figures 1). We choose not to perform open surgery for cosmetic reasons and because there were no signs of bowel necrosis. At laparoscopy, the small bowel was found to be herniating through a 2 × 2-cm defect in the left broad ligament (Figure 2). The incarcerated small bowel was slightly edematous but not ischemic. The defect was closed with a simple running suture using 3-0 Vicryl (Johnson & Johnson, New Brunswick, USA) via laparoscopy (Figure 3). After an uneventful postoperative course, the patient was discharged 4 days later.
Discussion Internal hernia is a rare cause of intestinal obstruction, reported in less than 1% of cases. An internal hernia is defined as the protrusion of an intra-abdominal viscus through or into the retroperitoneal fossae or a mesenteric defect. The various types of internal hernias include paraduodenal hernias (53%), pericecal hernias (13%), hernias through the foramen of Winslow (8%), sigmoid related hernias (6%) and transmesenteric hernias (8%). Herniation of the intestine through a defect in the broad ligament is the least common of the intestinal hernias,
Asian J Endosc Surg 7 (2014) 327–329 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
327
Broad ligament hernia
M Matsunami et al.
Figure 3 Closure of the broad ligament defect (arrow).
Figure 1 Multi-detector CT showed discontinuity of small bowel near the left broad ligament (arrow).
Figure 2 Left broad ligament defect inferior to round ligament (arrow).
accounting for only 4%. Quain reported the first case in 1861 from an autopsy study. Hernias through the broad ligament may be classified in two main ways, based on either the degree of peritoneal defect or the location of the defect within the broad ligament. In 1934, Hunt devised the first classification scheme based on the degree of the defect (3), which included three categories: (i) fenestra type, the most common, which is indicated by
328
the presence of a defect in the two peritoneal layers; (ii) pouch type, which is indicated by the presence of a defect in only one of the two layers, whereby the visceral structures would be trapped in the parametrial tissue; and (iii) hernia sac type, whereby a double layer of attenuated peritoneum lines the herniated bowel, forming a true internal hernia. The hernia sac would have to be obliterated to prevent recurrence. In 1986, Cilley et al. introduced a new classification of broad ligament defects based on the anatomical location, which included three categories: type 1, defect caudal to the round ligament; type 2, defect above the broad ligament; and type 3, defect between the round ligament and remainder of the broad ligament, through the mesoligametum teres (4). A type 3 broad ligament defect may be easily corrected by division of the round ligament. Our patient had a type 1 or fenestra type broad ligament defect. To prevent recurrence, we closed the defect by a running suture using 3-0 Vicryl via laparoscopy. The defect in the broad ligament may be classified as primary or secondary. Primary defects are often congenital and may arise from a developmental abnormality of the broad ligament or from the rupture of congenital cystic structures thought to be remnants of the mesonephric or müllerian ducts. Secondary or acquired defects may be due to inflammatory pelvic diseases, pregnancy, or injury following vaginal manipulation. The preoperative diagnosis of an internal hernia through a defect in the broad ligament is often difficult, as the clinical picture of SBO is non-specific. However, with advances in imaging techniques, preoperative diagnosis from multi-detector CT images has occasionally been made. The pathognomonic findings of SBO due to broad ligament hernia include: (i) SBO with a double transition zone located in the pelvis; (ii) a cluster of dilated small bowel loops herniated laterally to the uterus in the pelvic cavity; and (iii) enlargement of the distance
Asian J Endosc Surg 7 (2014) 327–329 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Broad ligament hernia
M Matsunami et al.
between the uterus and one of the ovaries, which are deviated in opposite directions (5). Laparoscopic surgery has gained an increasingly important role in the diagnosis and treatment of intestinal obstruction. Guillem et al. reported the first case of laparoscopic repair of a hernia through a broad ligament in 2003 (6), and since then, the procedure has become the mainstay of treatment for uncomplicated cases. The defect in the broad ligament is repaired primarily using clips or sutures, or the broad ligament can be completely divided (7–10). In cases in which the patient has SBO and suspected internal hernia, but there is no evidence of necrosis or perforation of the hernial contents, we believe the first choice should be a diagnostic laparoscopy because of ease, minimal aesthesia and minimal invasiveness. The differential diagnosis of internal hernia through a defect in the broad ligament should be borne in mind when a woman presents with an intestinal obstruction, even in a nulliparous woman with no previous abdominal surgery. Early recognition will allow for prompt surgical treatment of this unusual mechanical cause of obstruction. Multi-detector CT imaging may suggest the diagnosis, but diagnostic laparoscopy is ideal, as it allows for definitive diagnosis and effective surgical treatment.
Acknowledgments The authors have no conflicts of interest to disclose and received no financial support for this report.
References 1. Baron A. Defect in the broad ligament and its association with intestinal strangulation. Br J Surg 1948; 36: 91–94. 2. Hansmann GH & Morton SH. Intra-abdominal hernia: Report of a case and review of the literature. Arch Surg 1939; 39: 973–986. 3. Hunt AB. Fenestra and pouches in the broad ligament as an actual and potential cause of strangulated intra-abdominal hernia. Surg Gynecol Obstet 1934; 58: 906–913. 4. Cilley R, Poterack K, Lemmer J et al. Defects of the broad ligament of the uterus. Am J Gastroenterol 1986; 81: 389–391. 5. Barbier Brion B, Daragon C, Idelcadi O et al. Small bowel obstruction due to broad ligament hernia: Computed tomography findings. Hernia 2011; 15: 353–355. 6. Guillem P, Cordonnier C, Bounoua F et al. Small bowel incarceration in a broad ligament defect. Surg Endosc 2003; 17: 161–162. 7. Langan RC, Holzman K, Coblentz M. Strangulated hernia through a defect in the broad ligament: A sheep in wolf’s clothing. Hernia 2012; 16: 481–483. 8. Takayama S, Hirokawa T, Sakamoto M et al. Laparoscopic management of small bowel incarceration caused by a broad ligament defect: Report of a case. Surg Today 2007; 37: 437– 439. 9. Nozoe T & Anai H. Incarceration of small bowel herniation through a defect of the broad ligament of the uterus: Report of a case. Surg Today 2002; 32: 834–835. 10. Varela GG, López-Loredo A, García León JF. Broad ligament hernia-associated bowel obstruction. JSLS 2007; 11: 127– 130.
Asian J Endosc Surg 7 (2014) 327–329 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
329
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Broad ligament hernia successfully treated by laparoscopy: Case report and review of literature Masatoshi Matsunami, Hiroshi Kusanagi, Ken Hayashi, Shigetoshi Yamada & Nobuyasu Kano Department of Surgery, Kameda Medical Center, Chiba, Japan
Keywords Broad ligament hernia; laparoscopy; small bowel obstruction Correspondence Masatoshi Matsunami, Department of Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba 296–8602, Japan. Tel: 04 7092 2243 Email: [email protected]
Abstract We report a case of a 36-year-old woman with a history of caesarean section who presented with small bowel obstruction. Abdominal multi-detector CT showed discontinuity of the small bowel near the broad ligament on the left. We made a provisional diagnosis of an internal hernia through a defect in the broad ligament and performed laparoscopic exploration, which revealed a viable ileal loop incarcerated by the broad ligament. Multi-detector CT may be useful for diagnosing this type of defect preoperatively, whereby open surgery can be avoided.
Received 22 February 2014; accepted 11 May 2014 DOI:10.1111/ases.12119
Introduction According to a report by Baron (1), intestinal strangulation due to a broad ligament was initially reported by Quain in 1861. Internal hernia as a cause of small bowel obstruction (SBO) accounts for only 1% of all intestinal obstructions. Broad ligament internal hernia is extremely rare and constitutes 4% of all internal hernias (2). Laparoscopy is not usually recommended for SBO because of the difficulty in identifying the point of obstruction. However, once a hernia caused by the broad ligament has been diagnosed, we believe that the laparoscopic approach is better than an open procedure. We report a case of SBO diagnosed preoperatively and managed successfully by laparoscopic surgery.
Case Presentation A 36-year-old woman with a history of caesarean section was admitted to our hospital with lower abdominal pain and vomiting. The patient was afebrile and her vital signs were within normal limits. Physical examination disclosed a mildly distended abdomen with diffuse severe tenderness but no peritoneal signs. Laboratory findings were not suggestive of inflammation. Abdominal multi-
detector CT showed discontinuity of the small bowel near the left broad ligament (Figures 1). We choose not to perform open surgery for cosmetic reasons and because there were no signs of bowel necrosis. At laparoscopy, the small bowel was found to be herniating through a 2 × 2-cm defect in the left broad ligament (Figure 2). The incarcerated small bowel was slightly edematous but not ischemic. The defect was closed with a simple running suture using 3-0 Vicryl (Johnson & Johnson, New Brunswick, USA) via laparoscopy (Figure 3). After an uneventful postoperative course, the patient was discharged 4 days later.
Discussion Internal hernia is a rare cause of intestinal obstruction, reported in less than 1% of cases. An internal hernia is defined as the protrusion of an intra-abdominal viscus through or into the retroperitoneal fossae or a mesenteric defect. The various types of internal hernias include paraduodenal hernias (53%), pericecal hernias (13%), hernias through the foramen of Winslow (8%), sigmoid related hernias (6%) and transmesenteric hernias (8%). Herniation of the intestine through a defect in the broad ligament is the least common of the intestinal hernias,
Asian J Endosc Surg 7 (2014) 327–329 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
327
Broad ligament hernia
M Matsunami et al.
Figure 3 Closure of the broad ligament defect (arrow).
Figure 1 Multi-detector CT showed discontinuity of small bowel near the left broad ligament (arrow).
Figure 2 Left broad ligament defect inferior to round ligament (arrow).
accounting for only 4%. Quain reported the first case in 1861 from an autopsy study. Hernias through the broad ligament may be classified in two main ways, based on either the degree of peritoneal defect or the location of the defect within the broad ligament. In 1934, Hunt devised the first classification scheme based on the degree of the defect (3), which included three categories: (i) fenestra type, the most common, which is indicated by
328
the presence of a defect in the two peritoneal layers; (ii) pouch type, which is indicated by the presence of a defect in only one of the two layers, whereby the visceral structures would be trapped in the parametrial tissue; and (iii) hernia sac type, whereby a double layer of attenuated peritoneum lines the herniated bowel, forming a true internal hernia. The hernia sac would have to be obliterated to prevent recurrence. In 1986, Cilley et al. introduced a new classification of broad ligament defects based on the anatomical location, which included three categories: type 1, defect caudal to the round ligament; type 2, defect above the broad ligament; and type 3, defect between the round ligament and remainder of the broad ligament, through the mesoligametum teres (4). A type 3 broad ligament defect may be easily corrected by division of the round ligament. Our patient had a type 1 or fenestra type broad ligament defect. To prevent recurrence, we closed the defect by a running suture using 3-0 Vicryl via laparoscopy. The defect in the broad ligament may be classified as primary or secondary. Primary defects are often congenital and may arise from a developmental abnormality of the broad ligament or from the rupture of congenital cystic structures thought to be remnants of the mesonephric or müllerian ducts. Secondary or acquired defects may be due to inflammatory pelvic diseases, pregnancy, or injury following vaginal manipulation. The preoperative diagnosis of an internal hernia through a defect in the broad ligament is often difficult, as the clinical picture of SBO is non-specific. However, with advances in imaging techniques, preoperative diagnosis from multi-detector CT images has occasionally been made. The pathognomonic findings of SBO due to broad ligament hernia include: (i) SBO with a double transition zone located in the pelvis; (ii) a cluster of dilated small bowel loops herniated laterally to the uterus in the pelvic cavity; and (iii) enlargement of the distance
Asian J Endosc Surg 7 (2014) 327–329 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Broad ligament hernia
M Matsunami et al.
between the uterus and one of the ovaries, which are deviated in opposite directions (5). Laparoscopic surgery has gained an increasingly important role in the diagnosis and treatment of intestinal obstruction. Guillem et al. reported the first case of laparoscopic repair of a hernia through a broad ligament in 2003 (6), and since then, the procedure has become the mainstay of treatment for uncomplicated cases. The defect in the broad ligament is repaired primarily using clips or sutures, or the broad ligament can be completely divided (7–10). In cases in which the patient has SBO and suspected internal hernia, but there is no evidence of necrosis or perforation of the hernial contents, we believe the first choice should be a diagnostic laparoscopy because of ease, minimal aesthesia and minimal invasiveness. The differential diagnosis of internal hernia through a defect in the broad ligament should be borne in mind when a woman presents with an intestinal obstruction, even in a nulliparous woman with no previous abdominal surgery. Early recognition will allow for prompt surgical treatment of this unusual mechanical cause of obstruction. Multi-detector CT imaging may suggest the diagnosis, but diagnostic laparoscopy is ideal, as it allows for definitive diagnosis and effective surgical treatment.
Acknowledgments The authors have no conflicts of interest to disclose and received no financial support for this report.
References 1. Baron A. Defect in the broad ligament and its association with intestinal strangulation. Br J Surg 1948; 36: 91–94. 2. Hansmann GH & Morton SH. Intra-abdominal hernia: Report of a case and review of the literature. Arch Surg 1939; 39: 973–986. 3. Hunt AB. Fenestra and pouches in the broad ligament as an actual and potential cause of strangulated intra-abdominal hernia. Surg Gynecol Obstet 1934; 58: 906–913. 4. Cilley R, Poterack K, Lemmer J et al. Defects of the broad ligament of the uterus. Am J Gastroenterol 1986; 81: 389–391. 5. Barbier Brion B, Daragon C, Idelcadi O et al. Small bowel obstruction due to broad ligament hernia: Computed tomography findings. Hernia 2011; 15: 353–355. 6. Guillem P, Cordonnier C, Bounoua F et al. Small bowel incarceration in a broad ligament defect. Surg Endosc 2003; 17: 161–162. 7. Langan RC, Holzman K, Coblentz M. Strangulated hernia through a defect in the broad ligament: A sheep in wolf’s clothing. Hernia 2012; 16: 481–483. 8. Takayama S, Hirokawa T, Sakamoto M et al. Laparoscopic management of small bowel incarceration caused by a broad ligament defect: Report of a case. Surg Today 2007; 37: 437– 439. 9. Nozoe T & Anai H. Incarceration of small bowel herniation through a defect of the broad ligament of the uterus: Report of a case. Surg Today 2002; 32: 834–835. 10. Varela GG, López-Loredo A, García León JF. Broad ligament hernia-associated bowel obstruction. JSLS 2007; 11: 127– 130.
Asian J Endosc Surg 7 (2014) 327–329 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
329
