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CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 54-56

Unusual case of intestinal obstruction


1 Department of Anesthesia, AFMC, Pune, Maharashtra, India
2 Department of Anesthesiology, MediCiti Institute of Medical Sciences, Ghanpur, Hyderabad, Telangana, India

Date of Web Publication22-Mar-2018

Correspondence Address:
Dr. Pendyala Pradeep
Associate Professor, Department of Anesthesiology, MediCiti Institute of Medical Sciences, Ghanpur, Medchal, Hyderabad - 501 401, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_136_15

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  Abstract 


Internal hernia is a rare cause of small bowel loop obstruction. Hernia through a defect of the broad ligament is extremely rare. We report a case of small bowel obstruction resulting from the herniation of small bowel through a unilateral defect in the broad ligament in a woman who had no prior abdominal surgery, uterine surgery, delivery trauma, and pelvic pathology. Congenital abnormality should be considered the cause of the defect in the broad ligament.

Keywords: Broad ligament, internal hernia, intestinal obstruction


How to cite this article:
Murthy TV, Pradeep P. Unusual case of intestinal obstruction. J NTR Univ Health Sci 2018;7:54-6

How to cite this URL:
Murthy TV, Pradeep P. Unusual case of intestinal obstruction. J NTR Univ Health Sci [serial online] 2018 [cited 2020 Apr 4];7:54-6. Available from: http://www.jdrntruhs.org/text.asp?2018/7/1/54/228143




  Introduction Top


Identifying the cause of intestinal obstruction before exploring surgically is always a challenge. Internal hernia is a rare cause of intestinal obstruction, accounting for <1% of cases. Herniation of structures through a defect in the broad ligament is even more uncommon and accounts for only 4–5% of all internal hernias.[1]

We report the case of a 41-year-old woman with no previous abdominal surgery, who presented with symptoms of intestinal obstruction. Preoperative radiology, clinical examination, and ultrasonography could not reveal the exact cause. Exploration revealed herniation of a healthy jejunal loop through a broad ligament defect.


  Case Report Top


A 41-year-old woman presented with symptoms of vomiting, constipation, abdominal colic, and distension for a duration of 2 days. She had no previous abdominal surgery and is a mother of a child born normally. She was clinically dehydrated at presentation and had a distended abdomen with central and lower abdominal tenderness but no peritonism. There were no external herniae and bowel sounds were sluggish. The rectal and vaginal examinations were normal. Laboratory investigations were unremarkable. Abdominal radiographs showed centrally located, dilated, small bowel with multiple fluid levels. Ultrasonography corroborated the same findings with no additional inputs as to the causative reason.

The patient was treated with nasogastric decompression via a Ryles tube for 24 h, with no improvement of symptoms. As she did not show any improvement and abdominal distention persisted, it was decided to proceed for a surgical exploration. Surgical exploration revealed the jejunum and proximal ileum as the point of mechanical obstruction where the bowel had herniated through a 3 cm × 4 cm defect in the right broad ligament, involving both the anterior and posterior peritoneum. The viable herniated bowel was reduced and the defect in the broad ligament was repaired. The patient had an uneventful postoperative recovery.


  Discussion Top


Small bowel obstruction in a virgin abdomen is not an uncommon condition, and the etiology of obstruction may generally be thought of as arising from either within the lumen, mural disease, or extramural.

Internal hernia is a rare cause of intestinal obstruction, accounting for <1% of cases.[1] An internal hernia is defined as the protrusion of an intraabdominal viscus through or into the retroperitoneal fossae or a mesenteric defect. Herniation of structures through a defect in the broad ligament is uncommon and accounts for only 4–5% of all internal hernias.[1] The first case was reported by Quain in 1861, from an autopsy study.[2]

Herniae through the broad ligament may be classified into two main ways: based either on the degree of peritoneal defect or the location of the defect within the broad ligament. The first classification was described by Hunt in 1934 based on the degree of the defect [3] as: (1) Fenestra type, (2) Pouch type, and (3) Hernia sac type. In 1986, Cilley introduced a new classification of broad ligament defects based on the anatomical location.[4]

  1. Type I: defect caudal to the round ligament;
  2. Type II: defect above the broad ligament;
  3. Type III: defect between the round ligament and remainder of the broad ligament, through the meso-ligamentum teres.


In this case, our patient had a Type I, fenestra type broad ligament defect. The cause of a defect in the broad ligament may be classified as primary or secondary. Primary congenital defects may arise from a developmental abnormality of the broad ligament or from the rupture of congenital cystic structures and are thought to be remnants of the mesonephric or Mullerian ducts. Secondary or acquired defects may be due to inflammatory pelvic diseases, pregnancy, or injury following vaginal manipulations. Defects in the broad ligament after pelvic operations such as the repair of an obturator hernia, laparoscopic sterilization, and electrocoagulation therapy of endometriosis have also been reported.[5] Majority of the cases reported in the literature are unilateral and secondary in nature. It is rare to have a unilateral defect that is primary in nature such as in our case.[6]

A review of the case reports reveals the most common content of a hernia through a defect in the broad ligament to be the small bowel, especially the ileum. The sigmoid colon, cecum, appendix, and ovary have been reported to herniate through a broad ligament defect, resulting in complications such as bowel ischemia, ileovaginal fistula, and strangulation of the ovary.[7]

The preoperative diagnosis of an internal hernia through a defect in the broad ligament is often difficult as the clinical picture of small bowel obstruction is nonspecific. However, with the advances in imaging techniques, preoperative diagnosis is easier. The pathognomonic radiological feature of small bowel obstruction due to a broad ligament hernia is a closed-loop small bowel obstruction with a hernia located lateral to the uterus. Additional computed tomography (CT) features include medial rotation of the involved broad ligament and fallopian tube or a widened distance between the uterus and the ipsilateral ovary.[8]

Laparoscopic surgery has gained an increasingly important role in the diagnosis and treatment of intestinal obstruction. The potential for therapeutic manipulation during the same setting has become the mainstay of treatment for uncomplicated cases. It is prudent to examine the contralateral broad ligament during the operation in order not to miss any other similar defect.

The differential diagnosis of the rare internal hernia through a defect in the broad ligament should be borne in mind in a woman with intestinal obstruction, even in a nulliparous female with no previous abdominal/pelvic surgery.[9],[10] Early recognition will allow for prompt surgical treatment of this unusual mechanical cause of obstruction. CT imaging may suggest the diagnosis. Diagnostic laparoscopy is ideal as it allows for definitive diagnosis and effective surgical treatment. The case is being reported in view of its rarity and for general awareness in such similar clinical situations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Slezak FA, Schlueter TM. Hernia of the broad ligament. Hernia 1995;4:491-7.  Back to cited text no. 1
    
2.
Quain. Case of internal strangulation of a large portion of the ileum. Trans Pathol Soc Lond 1861;12:103-4.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
    
4.
Cilley R, Poterack K, Lemmer J, Dafoe D. Defects of the broad ligament of the uterus. Am J Gastroenterol 1986;81:389-91.  Back to cited text no. 4
[PUBMED]    
5.
Redwine DB. Symptomatic internal hernia of the broad ligament: A complication of electrocoagulation therapy of endometriosis. Obstet Gynecol 1989;73(Pt 2):495-6.  Back to cited text no. 5
    
6.
Ngabou UD, Hornez E, Chiron P, Fondin M, Pons F. Internal hernia through a defect in the broad ligament. J Visc Surg 2012;149:161-2.  Back to cited text no. 6
    
7.
Demir H, Scoccia B. Internal herniation of adnexa through a defect of the broad ligament: Case report and literature review. J Minim Invasive Gynecol 2010;17:110-2.  Back to cited text no. 7
[PUBMED]    
8.
Barbier Brion B, Daragon C, Idelcadi O, Mantion G, Kastler B, Delabrousse E. Small bowel obstruction due to broad ligament hernia: computed tomography findings. Hernia 2011;15:353-5.  Back to cited text no. 8
[PUBMED]    
9.
Natasha G, Leo B, Josef B. Bowel Herniation through Broad Ligament mimicking ovarian torsion: A novel presentation. J Clin Gynaecol Obstet 2013;2:93-5.  Back to cited text no. 9
    
10.
Yeung KW, Chang MS, Chiang PT. Internal Hernia through a defect of broad ligament. J Radiol Sci 2011;36:125-8.  Back to cited text no. 10
    




 

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