Intestinal Obstruction Due to an Internal Hernia through a Defect of the Broad Ligament in an Adult Female Patient: Case Report and Literature Review

Abstract

Internal hernia is a rare cause of intestinal obstruction. We present a case of 43-year-old woman without any prior surgical history who was referred as a case of obstructed para-umbilical hernia from a satellite clinic. The objective is to highlight the occurrence of such a rare clinical problem and to provide an insight into decision making especially when there is discordance between an obvious pathology and clinical features.

Broad-Ligament Hernia: A Rare Cause of Small Bowel Obstruction

“…The most common being the left paraduodenal hernias (53%), followed by pericecal, foramen of Winslow, and transmesenteric hernias, respectively. 2 Acquired cases arise from herniation of a segment of bowel around or through surgically created entrapments, 1 such as the Petersen hernia that occurs after Roux-en-Y gastric bypass.…”

“…In the latter, it can be caused by trauma during pregnancy or vaginal delivery, surgery, pelvic inflammatory disease, or, in nulliparous women, spontaneous rupture of cystic structures within the broad ligament that are thought to be remnants of the mesophrenic or mullerian ducts. 2,3 The correct preoperative diagnosis is challenging, and most reported cases in the literature were diagnosed during exploratory laparotomy or at autopsy. 3 We herein present a case of SBO due to BLH, diagnosed preoperatively by abdominal CT scan and treated by early surgery.…”

“…BLHs, first reported by Qurain in 1861 from an autopsy series, 2 are extremely rare and constitute only 4 per cent of all internal hernias. 4 They are classified by two ways, either by the degree of peritoneal defect proposed by Hunt or the location of the defect within the broad ligament proposed by Cilley.…”

“…The Hunt's classification appeared in 1934 and includes the fenestra type, where the defect is in the peritoneal layers; the pouch type, where the viscera is trapped within parametrial tissue because of a defect in one peritoneal layer; and the hernia sac type, where a double layer of attenuated peritoneum lines the herniated viscus, forming a true hernia sac which should be obliterated to prevent recurrence. 2 Cilley proposed a new classification in 1986 according to the location of the defect: type 1, the defect is caudal to the round ligament; type 2, the defect is above the broad ligament; and type 3, the defect is between the round ligament and the rest of the broad ligament, through the ligamentum teres. 2 Clinical diagnosis is challenging, because most patients have nonspecific symptoms and are diagnosed only after an episode of SBO.…”

“…2 Cilley proposed a new classification in 1986 according to the location of the defect: type 1, the defect is caudal to the round ligament; type 2, the defect is above the broad ligament; and type 3, the defect is between the round ligament and the rest of the broad ligament, through the ligamentum teres. 2 Clinical diagnosis is challenging, because most patients have nonspecific symptoms and are diagnosed only after an episode of SBO.…”