Dawit Worku, MD, MSc, MRCSEd, Abdulzahra Hussain, FRCSI, FRCSEng. Airedale Hospital NHS Foundation Trust
A healthy 37 year old multiparous woman presented to an emergency department with one day history of nausea, repeated vomiting, abdominal distension and obstipation. She had no previous history of abdominal surgery. On examination, she was reporting significant pain but was maintaining normal vital signs. Her abdomen was distended, with mild tenderness in the lower quadrants and hyperactive bowel sounds. The results of basic laboratory investigations (i.e., complete blood count, electrolyte panel and inflammatory markers) were normal. Computed tomography showed dilated loops of distal small bowel with transition area in the right pelvis, consistent with complete obstruction of the small bowel.
Initially, she was managed conservatively with intravenous fluids, nasogastric tube and nothing by mouth for the first 24 hours. When the conservative treatment failed, diagnostic laparoscopy was carried out. The findings were internal herniation of small bowel loops through a 6cm defect in the uterine broad ligament, between the round ligament and right adenexa. After reduction of the herniated bowel, the broad ligament defect was closed with intracorporeal suturing to prevent recurrence. The patient made an uneventful recovery post operatively and was discharged home few days later.
Herniation through a defect in the uterine broad ligament remains an uncommon cause of intestinal obstruction, accounting for about 4%–7% of internal hernias. Thus, it poses a significant diagnostic challenge pre-operatively. However, the possibility of internal herniation through a defect in the broad ligament should be considered in women presenting with obstruction of the small bowel when more common causes (i.e., adhesions, neoplasms, groin hernias) have been excluded.
Defects of the broad ligament may be either acquired or congenital. Acquired causes include trauma resulting from pregnancy or delivery, pelvic inflammatory disease or surgery is an acquired cause. In nulliparous patients, such defects may result from spontaneous rupture of cystic structures within the broad ligament that are thought to be congenital remnants of the mesonephric or mullerian ducts. Herniation or obstruction of the small bowel is the most commonly reported complication.
The management of small bowel obstruction secondary to herniation through broad ligament is operative, once conservative options are exhausted. A Trendelenburg position intraoperatively can assist in gentle reduction of incarcerated contents. Non viable bowel should be resected. Prevention of recurrent small bowel obstruction can be achieved by either closure of the defect (i.e. using clips or suture) or by dividing the broad ligament completely.
As this case demonstrates, small bowel obstruction due to herniation through uterine broad ligaments can safely be managed laparoscopically.
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