Broad ligament hernias are a rare cause of intestinal obstruction in women who present with bowel obstruction. Approximately 150 cases have been reported in the international literature.^1-22 A majority of these cases included incarceration of the ileum.^1-12 Congenital defects, endometriosis, trauma during delivery, pelvic inflammatory disease, and iatrogenic causes account for most etiologies in women.

Because broad ligament hernias are difficult to diagnose preoperatively using radiography, most cases are identified and treated using exploratory laparotomy. Laparoscopic reduction and repair is an alternative treatment option. We report a case of herniation through the broad ligament in a 47-year-old woman who was treated using a laparoscopic approach, and we review the literature.

Case report
A 47-year-old white woman presented to the emergency department reporting lower abdominal pain and nausea. An initial computed tomography (CT) scan revealed several loops of dilated small intestine and left colon wall thickening, possibly indicating diverticulitis. Outpatient therapy with oral ciprofloxacin and metronidazole was administered.

The patient returned to the emergency department 8 days later reporting diffuse colicky abdominal pain, nausea, and bilious emesis of 24 hours’ duration. Her medical history was significant only for glaucoma; she had no history of endometriosis or previous abdominal surgery. She had two uncomplicated, vaginal deliveries in the distant past. The patient smoked half a pack of cigarettes daily for approximately 20 years. Her family history was unremarkable.

The patient’s physical examination on admission to the hospital revealed a temperature of 98.3°F, a pulse rate of 110 beats per minute, and initial nasogastric tube output of 1,000 mL of feculent, bilious content. Her abdomen was distended but soft, with no masses, rebound, or guarding on palpation. Mild tenderness was elicited bilaterally in the lower abdomen. Her rectal examination was negative.

Abdominal radiographs taken on admission showed dilated loops of small intestine and air-fluid levels. Another CT scan was taken, and this revealed a distal small bowel obstruction with no inflammatory changes or masses (Figure 1). Laboratory analysis demonstrated a leukocyte count of 10 K/µL without bandemia, a potassium level of 2.4 mEq/L, a chloride level of 75 mEq/L, and an anion gap of 18.

After aggressive fluid and electrolyte resuscitation, surgical consultation was obtained on hospital day 2. Abdominal radiographs confirmed partial resolution of the small intestine’s dilatation. Although the patient’s abdominal examination at that time exhibited less distention and no tenderness, the output from the nasogastric tube remained voluminous. The decision to operate was made.

Laparoscopy revealed an internal hernia whereby a loop of distal ileum was incarcerated within a 3-cm defect of the left broad ligament (Figure 2). The viable ileum was reduced laparoscopically, and the defect was closed using a 2-0 silk suture, placed in a figure-of-eight pattern (Figure 3). The patient’s right broad ligament appeared normal. Inspection of the posterior cul-de-sac found minute areas of endometriosis that were fulgurated.

The nasogastric tube was removed, and the patient’s diet was advanced on postoperative day 1. She developed cephalic vein thrombosis as a result of an indwelling peripherally inserted central catheter. After the catheter was removed, she was treated with subcutaneous enoxaparin and oral aspirin. She was discharged on postoperative day 3 and remained asymptomatic at a follow-up examination 14 months later.

Discussion
Internal hernias account for only 1% of all intestinal obstructions.¹³ Defects in the broad ligament resulting in bowel obstruction account for 4% to 7% of all internal hernias.² Approximately 150 cases of broad ligament hernias are reported in the literature.^1-22 The average age at diagnosis is 47 years.¹⁴ Ileal incarceration accounts for most obstructions. Other herniated structures include the jejunum, cecum, sigmoid colon, ovaries, and ureter.^5,15,16

In 1861, anatomist Quain first described a defect in the ligamentum latum uteri (broad ligament) discovered during an autopsy.⁷ Hunt classified broad ligament defects into two types: fenestrated, which involves a defect in the anterior and posterior leaves of the broad ligament; and pouch, which incorporates a single-layer defect.¹⁷ Haku and colleagues discuss Terado’s review of 57 cases of broad ligament hernias reported in the Japanese literature from 1977 to 2002, in which he found that 95% could be classified as fenestrated defects.¹

The proposed pathogenesis of broad ligament defects includes pregnancy, trauma during delivery, pelvic inflammatory disease, iatrogenic injury, endometriosis, and congenital defects.² Terado’s findings combined with data reported in the English-language literature from 1965 to 2006 indicate that 92% of women (58 of 63) discovered to have broad ligament hernias reported a history of pregnancy^1-17,20-22; however, such defects also have been reported in nulligravid women, including those with no history of abdominal surgery, endometriosis, trauma, or pelvic inflammatory disease.^13,16 This means that a primary congenital etiology is plausible. Supporting the theory of congenital origin, Gray and Skandalakis refer to a “cystic structure” in the broad ligament, which may be a remnant of the mesonephric duct.¹⁸ Rupture of this cystic structure may account for congenital defects in the broad ligament.

Iatrogenic defects result mainly from ablation therapy to treat endometriosis. Redwine described the case of a patient who underwent laparoscopic fulguration of an endometrioma and was found to have a 4 x 4-cm broad ligament defect during a second laparoscopy 6 months later.¹⁶ This defect was not repaired, and after 2 years of intermittent right lower quadrant pain, a third laparoscopy revealed an ileocecal herniation through the right broad ligament. The hernia was reduced and repaired via a mini-laparotomy.

Historically, several cases of iatrogenic broad ligament defects occurred as a result of the Baldy-Webster technique for uterine suspension.^5,6 The Baldy-Webster technique was first described in 1901, and the procedure involved creating a broad ligament opening to correct retroversion of the uterus.¹⁹ Improper closure of the incurred defects resulted in broad ligament hernias.¹⁰

CT scanning has been used with limited success to diagnose broad ligament hernias preoperatively. Although this modality occasionally identifies a loop of dilated small intestine in an aberrant location displacing the uterus, it generally shows nonspecific obstruction of the distal small intestine.²⁰ Several authors have commented on the preoperative benefits of CT scanning.^1,3,7,20 Most agree that in their cases, the scans did not establish a definitive diagnosis but confirmed intraoperative findings retrospectively.^3,7

Operative management of broad ligament hernias discussed in the literature depended on their degree of complexity. The surgeon’s ability to reduce the internal hernia successfully during laparotomy dictated the repair technique. In cases where infarction or perforation occurred and reduction was difficult, a salpingo-oophorectomy was performed, with bowel resection.^3,5,6,10 When reduction was successful, repair included applying an absorbable clip and suturing with polyglactin-910 or silk sutures. Current recommendations suggest using nonabsorbable sutures.¹⁴ 

Most of the reported cases from 1965 to 2006 noted a unilateral predominance.^1-17,20,22 Simstein suggested a right-sided predilection, but a review by Stern and Warner showed an equal right and left frequency.^6,14 Four cases of bilateral defects have been reported over the past 40 years.^3,8,9,11 Most authors concur that if a unilateral broad ligament hernia is identified, the contralateral side should be inspected.

 Laparoscopy facilitates the diagnosis of broad ligament hernias and offers a minimally invasive treatment option. All of the cases reported before 2003 note that diagnosis was established and the defect was repaired during laparotomy.^1,3-17,20-22 Guillem and associates performed the first totally laparoscopic procedure.² A viable loop of ileum was reduced and the defect was closed laparoscopically with an absorbable clip.

Based on our literature review, our case is the first laparoscopically diagnosed and treated broad ligament hernia in North America and the second in the world. Our patient’s defect is classified as fenestrated. She had no preoperative symptoms of endometriosis. Preoperatively, the second CT scan assisted only in confirming a distal small bowel obstruction. Restrospective review of the CT scan demonstrated an aberrant loop of small intestine, suggesting a broad ligament defect. Although the actual origin of our patient’s defect remains unclear, possible etiologies include her previous pregnancies, congenital defects, or endometriosis.

Conclusion
Incarcerated hernias resulting from broad ligament defects represent only 0.0004% to 0.0007% of all intestinal obstructions.²² Although the pathogenesis of these defects remains elusive, evidence supports both acquired and congenital origins. Broad ligament defects should be considered in any female patient who presents with bowel obstruction. Although CT scanning can be beneficial, the diagnosis is seldomly confirmed preoperatively. Laparoscopy provides a unique opportunity to render a diagnosis and repair the hernia.

References
1. Haku T, Daidouji K, Kawamura H, et al. Internal herniation through a defect of the broad ligament of the uterus. Abdom Imaging. 2004;29(2): 161-163.

2. Guillem P, Cordonnier C, Bounoua F, et al. Small bowel incarceration in a broad ligament defect. Surg Endosc. 2003;17(1):161-162.

3. Ishihara H, Terahara M, Kigawa J, et al. Strangulated herniation through a defect of the broad ligament of the uterus. Gynecol Obstet Invest. 1993;35(3):187-189.

4. Ritchie AJ, Humphreys WG. Internal herniation of small bowel through a broad ligament defect. Br J Hosp Med. 1991;45(2):109. 

5. Bolin TE. Internal herniation through the broad ligament. Case report. Acta Chir Scand. 1987;153(11-12):691-693.

6. Simstein NL. Internal herniation through a defect in the broad ligament. Am Surg. 1987;53(5):258-259.

7. Suzuki M, Takashima T, Funaki H, et al. Radiologic imaging of herniation of the small bowel through a defect in the broad ligament. Gastrointest Radiol. 1986;11(1):102-104.

8. Leahy PF, Galvin C. Small bowel obstruction through a defect in the broad ligament. Ir Med J. 1984;77(11):355.

9. Armstrong CP, Drummond A. Small bowel obstruction and perforation through a defect in the broad ligament. J R Coll Surg Edinb. 1983;28(5): 333-334.

10. Mersheimer WL, Kazarian KK, Roeder WJ. Internal hernia due to defects in the broad ligament: report of two cases. Rev Surg. 1973;30(4):241-245.

11. Petereit MF. Internal hernia through a mesosalpinx defect: a rare cause of distal mechanical small bowel obstruction. Case report. S D J Med. 1973;26(5):29-30.

12. Johnson GL. Intestinal obstruction secondary to a hiatus in the uterine broad ligament. Mil Med. 1965;130(10):1014-1015.

13. Hiraiwa K, Morozumi K, Miyazaki H, et al. Strangulated hernia through a defect of the broad ligament and mobile cecum: a case report. World J Gastroenterol. 2006;12(9):1479-1480.

14. Stern LE, Warner BW. Congenital internal abdominal hernias: incidence and management. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and Condon’s Hernia. 5th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2002:462-465.

15. Kanbur AS, Ahmed K, Bux B, et al. Jejunal obstruction and perforation resulting from herniation through broad ligament. J Postgrad Med. 2000;46(3):189-190.

16. Redwine DB. Symptomatic internal hernia of the broad ligament: a complication of electrocoagulation therapy of endometriosis. Obstet Gynecol. 1989;73(3 Pt 2):495-496.

17. Hunt AB. Fenestrae and pouches in the broad ligament as an actual and potential cause of strangulated intra-abdominal hernia. Surg Gynecol Obstet. 1934;58:906-913.

18. Gray SW, Skandalakis JE. Embryology for Surgeons. Philadelphia, Pa: Saunders; 1972:640-645.

19. Speert H. John Clarence Webster, John Montgomery Baldy, and their operation for uterine retroversion. Surg Gynecol Obstet. 1956;102(3): 377-380.

20. Tanaka M, Kaneko Y, Ietsugu K, et al. Internal herniation through a broad ligament defect after obturator hernia repair. Surg Today. 1994;24(7): 634-637.

21. 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(9):834-835.

22. Livaudais W Jr, Hartong JM, Otterson WN. Small bowel herniation through a defect in the broad ligament. Am J Obstet Gynecol. 1979;133(8):927-928.

Self-Assessment Questions
Choose the best answer for each question.

1. Broad ligament defects occur as a result of all the following, except:
a)  pelvic inflammatory disease.
b) endometriosis.
c)  congenital malformation.
d)  necrosis of tumor implants.
e)  trauma during delivery.

2. Identify the false statement:
a)  Internal hernias represent 1% of all intestinal obstructions.
b) Pregnancy appears to be a significant risk factor in the development of a broad ligament defect.
c) Jejunal incarceration accounts for the majority of broad ligament obstructions.
d)  Ablation of endometrial implants may result in broad ligament defects.
e)  The broad ligament is composed of anterior and posterior leaves.

3. Identify the false statement:
a)  Mesh repair of large broad ligament defects has been reported.
b)  Salpingo-oophorectomy may be necessary to reduce a broad ligament hernia.
c)  Resection of the incarcerated organ depends mainly on its viability after reduction.
d)  Broad ligament defects have been described in nulligravid women with no previous abdominal or pelvic surgery.
e)  The Baldy-Webster technique for uterine suspension is associated with iatrogenic broad ligament defects.

4. Identify the true statement:
a)  Broad ligament defects have a left-sided predominance.
b)  Broad ligament defects have a right-sided predominance.
c) All of the reported cases of broad ligament hernias were diagnosed intraoperatively rather than by preoperative CT scan.
d)  Postmenopausal women with an incarcerated broad ligament hernia should undergo salpingo-oophorectomy to prevent recurrence.
e)  Bilateral defects are associated with endometriosis.