Less invasive treatment for broad ligament hernia: A case report

Characteristics and Associated Risk Factors of Broad Ligament Hernia: A Systematic Review

The broad ligament, a double-layered peritoneum attaching the lateral uterus to the pelvic sidewall, plays a vital role in pelvic anatomy. Small bowel herniation through a defect in the broad ligament, known as broad ligament herniation, involving protrusion of viscera through defects in this ligament, is rare but can lead to severe complications. This systematic review aims to evaluate the presentation, diagnosis, management, and factors associated with broad ligament herniation. Following PRISMA guidelines, a systematic search was conducted in PubMed and Cumulative Index to Nursing and Allied Health Literature databases using the terms "broad ligament AND hernia" and "broad ligament AND herniation". Case reports and series with detailed anatomical descriptions were included. Articles not in English or without full-text access were excluded. Extracted data included patient demographics, history of abdominal surgeries, herniated organs, and classification. Results were synthesized to identify patterns and risk factors. A total of 71 articles met the inclusion criteria, with patients predominantly aged 30 to 49 years. A history of abdominal surgery and multiparity were noted to be key risk factors. The small bowel was the most herniated organ (90% of cases). The fenestra type defect accounted for 88.9% of cases, and CT imaging emerged as the preferred diagnostic modality. Detailed surgical and medical histories are crucial in diagnosing broad ligament herniation. Future research should focus on pathogenesis and standardized classification systems to improve management strategies.

Quain hernia - A rare cause of acute small bowel obstruction. A case report and an updated literature review

Introduction and importance

Internal herniae are a rare cause of acute small bowel obstruction (SBO), accounting for <1% of all causes of SBO. Given their low incidence and often vague presenting symptoms there can be a delay in their diagnosis - which can lead to unnecessary morbidity for patients.

Case presentation

We present a case of a 34 year-old nulliparous female who presented with acute abdominal pain and transpired to have a closed loop obstruction of her ileum through a congenital defect in her broad ligament, or a Quain hernia.

Discussion

This paper will describe this case and provide an updated literature review of Quain herniae from recent research. With regards to surgical management of these hernia, both laparoscopic and open approaches are appropriate as long as appropriately trained surgical staff are involved. If a contraltateral defect in the Broad ligament is identified, this should be repaired prophylactically at the time in order to prevent future instances of internal herniation.

Conclusion

Increased awareness of the potential presenting symptoms and radiological features of Quain hernia, as outlined in this paper, is vital in order to reduce patient morbidity and mortality.

•

Quain hernia is a subtype of internal hernia caused by a defect in the broad ligament.

•

Their lack of recognition often leads to a delayed diagnosis and increased patient morbidity.

•

Both open and laparoscopic repair are suitable in appropriately trained individuals.

•

Contralateral defects should be fixed prophylactically to prevent future herniation.

Herniation Through Defects in the Broad Ligament

Background

We sought to assess hernia characteristics and classification through comprehensive review of the literature involving broad ligament herniation.

Methods

A literature search via MEDLINE and Embase databases was conducted to identify and select broad ligament herniation studies published between January 1, 2000 and September 30, 2020. Extracted data included previous surgical history, previous obstetric history, diagnostic imaging, herniated organ, hernia classification, and repair performed. The reported data has been compared to a unique case of broad ligament herniation that presented to our institution.

Results

A total of 44 articles with 49 cases were identified for the study. Eighteen (36.7%) patients had a history of previous abdominal surgery while 29 (59.2%) had a history of previous childbirth. Type I (51.0%) and Type II (18.4%) defects were most commonly reported with most patients reporting only one defect (85.7%) using the Cilley classification. Twenty-nine patients underwent primary laparoscopic repair of the defect while 19 patients underwent exploratory laparotomy.

Conclusions

The analysis of previously reported cases adds to the limited literature on broad ligament hernias and highlights the surgical management of this uncommon pathology. It also highlights the need for a broad differential diagnosis when female patients present with pelvic pain or symptoms of small bowel obstruction. The broad ligament should be fully inspected when mesenteric defects are suspected as multiple defects can be present as evidenced by the attached case study.

Broad ligament hernia: Two contrasting ways to a common goal - Two case reports with review of literature

Introduction

Broad ligament hernia (BLH) is a rare but potentially life threatening condition. One of the two cases described here is the only reported case of BLH in recent literature, where marsupialisation was done. These two case reports comprise the only reported side by side pictorial comparison of the two laparoscopic surgical therapeutic options for BLH.

Presentation of cases

Both patients presented with classical symptoms and signs of acute intestinal obstruction. Imaging confirmed obstructed left BLH in case 2 and indicated a complete small bowel obstruction in case 1. Both cases were successfully managed laparoscopically. Both patients had an uneventful immediate postoperative recovery and have not had recurrence over a mean follow up period of 34.5 months.

Discussion

BLH is rare among all types of internal herniae. It accounts for only 4% of internal herniae and is a difficult condition to diagnose. The advent of computed tomography has increased chances of accurate preoperative diagnosis.

Conclusion

BLH can be successfully managed by minimally invasive surgery, even in the acute setting. When tightly entrapped bowel is unyielding; it is better not to risk injury to it by aggressive attempts at its reduction. It is safer to attempt widening of the defect into which it is entrapped, whenever feasible.

•

Internal herniae are a rare cause of acute bowel obstruction

•

Among internal herniae, broad ligament hernia is even more uncommon

•

One of the two cases described in this paper is the only reported case of BLH in literature, where marsupialization was done

•

This is the only paper with a pictorial comparison of the two contrasting ways in which this condition can be treated

Rare Contents of an Internal Hernia through a Defect of the Broad Ligament of the Uterus

Herniation through a defect of the uterine broad ligament is a rare internal hernia that is difficult to diagnose definitively. Common hernia contents contain ileal loops. Herein, we report a rare case of internal herniation of both the ileum and fallopian tube through a defect of the broad ligament. A 52-year-old woman presented to our hospital with suprapubic pain and vomiting. She had a history of bowel obstruction following cesarean section. On abdominopelvic computed tomography, we suspected a closed-loop obstruction associated with bowel herniation in the right broad ligament. However, we could not identify an area of poor enhancement adjacent to distended small intestines. Emergency laparoscopic exploration revealed a viable ileal loop and incarcerated organ. Therefore, we switched to laparotomy that revealed the right fallopian tube as the ischemic organ. We reduced the hernia, resected necrotic right fallopian tube, and closed the defect of the broad ligament. The patient had an uneventful postoperative course. Rare hernia contents might complicate preoperative clinical diagnosis. Laparoscopy is useful for establishing a definitive diagnosis and treating broad ligament hernias.

Recurrence hernia in the broad ligament of the uterus: a case report

Background

Bowel herniation through a defect in the broad ligament of the uterus is a rare disease and few cases of recurrence have been reported. We report herein a recurrence case of a patient with broad ligament hernia (BLH), along with a review of the literature.

Case presentation

A 53-year-old woman complaining of abdominal pain was transported to our hospital. She had a history of laparotomy for small-bowel obstruction associated with hernia in the broad ligament of the uterus 10 years ago at a local hospital. Abdominal pelvic contrast-enhanced computed tomography revealed that the mesentery of the dilated bowels converged at a thick band in the pelvis, suggesting closed loop obstruction of the small bowel. The patient underwent urgent laparotomy and was diagnosed with bowel herniation through an opening in the broad ligament of the uterus on the right side, which was ipsilateral with the previous surgery. The hernia orifice was widened by incision and incarcerated bowel segments were released and preserved because ischemia was reversible. The membranous defect of BLH was closed by suture with braded silk strings.

Conclusions

Although BLH is a rare disease, patients face a significant risk of disease recurrence. Nonabsorbable suture may be advisable for closure of the hernia orifice in BLH.