The Diagnostic Challenges of Strangulated Broad Ligament Hernia: A Case Report

An internal hernia occurs when abdominal organs protrude through a defect in the peritoneum or mesentery [1]. It is a rare cause of acute bowel obstruction and accounts for 4% to 7% of cases due to defects in the broad ligament [2,3] . These defects may be congenital or result from factors such as abdominal surgery, pelvic inflammatory disease or trauma during childbirth. 

Because there are no specific symptoms or signs, diagnosing a strangulated internal hernia through a defect in the broad ligament of the uterus preoperatively is challenging [4]. During surgery, most patients with a broad ligament defect are identified. We report in this observation a case of internal hernia of the broad ligament revealed by intestinal obstruction in our surgery department at the regional hospital of Jendouba.

A 34-year-old multiparous female patient, with no medical or surgical history, was initially admitted to our department for acute abdominal pain and persistent vomiting evolving for two days. Physical examination revealed a tympanic, distended abdomen, but no fever, masses, or hernias were noted, and the rectal exam was normal. An abdominal X-ray examination showed differential air-fluid levels (Figure 1).

 Figure 1: Plain abdominal radiograph showed multiple air-fluid levels in the small bowel loops. 

To assess the site of the obstruction and check for evidence of ischemia, an abdominal computed tomography (CT) was performed.  The CT scan revealed dilated small bowel loops with two transitional zones located on the right side of the uterus (Figure 2).

 Figure 2: Axial abdominal CT scan revealed a small bowel obstruction. 

The initial diagnosis was acute bowel obstruction due to bridle strangulation. After initial resuscitation and stabilization, the patient underwent emergency surgery via midline laparotomy. During the exploration, dilated small bowel loops were found in front of an incarcerated loop. Upon extracting the incarcerated loop, a defect in the right broad ligament was identified (Figure 3).

 Figure 3: Operative image of the broad ligament hernia. 

Defect in the right broad ligament (black arrow) lateral to the uterus (black star) 

The hernia content was successfully reduced, and there was no evidence of ischemia or necrosis. The broad ligament hernia was repaired with 2-0 Vicryl® sutures (Figure 4).  The postoperative course was uneventful, and the patient was discharged on the fourth day following surgery. There was no evidence of recurrence at the one year follow-up.

 Figure 4: The result after surgical repair with simple sutures (black arrow).

Acute Intestinal obstruction is frequently encountered by emergency physicians, radiologists, and surgeons in emergency departments [4]. Internal hernias are rare, accounting for up to 2% of all small bowel obstruction cases, while broad ligament hernias represent a very rare subset, constituting 4–5% of internal hernias. If strangulated and left untreated, internal hernias can result in an overall mortality rate exceeding 50% [5]. 

These type of hernia is typically characterized  by the engagement, most often, of an ileal loop in an orifice located under the fallopian tube [6]. The first case was described in 1861 by Quain during an autopsy [3]. 

Although the small intestine is the most commonly reported herniated organ, rare cases of adnexal and sigmoid colon hernia have also been reported [7]. The broad ligament defects may be congenital or acquired following abdominal surgery, pelvic inflammatory disease or childbirth trauma [2].

Preoperative suspicion and diagnosis in the emergency setting are challenging due to the rarity of broad ligament hernias, their nonspecific clinical presentation, and limitations in imaging. Early diagnosis and prompt management are crucial, as delayed diagnosis can result in intestinal necrosis, peritonitis, and even death [5,8]. 

While computed tomography scans might indicate an internal hernia, accurately diagnosing a broad ligament hernia can be challenging. A prompt and astute clinical evaluation, supported by emergency radiological resources, is essential for establishing an early and timely diagnosis. Once identified, urgent surgical intervention is required, as any delay could lead to permanent damage to the herniated structure.

Thus, management always involves urgent surgical exploration. The principles of intervention include prompt action to prevent bowel strangulation, reduction of the hernia, resection of any non viable bowel segments, and repair of the defect [9,10]. 

Treatment is always surgical. The mortality rate for non-operative management of incarcerated or strangulated internal hernias approaches 100%, and delays in surgical intervention can result in significant morbidity. The surgical approach is typically straight forward and often involves nothing more than simple manual reduction  [11].

The defect in the broad ligament can be either unilateral or bilateral. During surgery, the contralateral broad ligament should always be examined for defects, and if present, repaired to prevent recurrence. Surgery should not be delayed to avoid increased morbidity and mortality [10]. The literature reports some successful cases of broad ligament hernias treated with laparoscopic surgery. However, most surgical teams prefer a laparotomic approach, as all patients exhibited significant distension of the small intestine. This distension increases the risk of complications during laparoscopic surgery due to the reduced peritoneal space. Additionally, the distended intestine becomes more fragile, further raising the risk of iatrogenic intestinal perforation [2,12].

Although rare, the diagnosis of an internal hernia through a defect in the broad ligament should be considered when a female patient presents with acute intestinal obstruction. Preoperative diagnosis is challenging and poses a significant difficulty for the surgeon. Early recognition of small bowel obstruction caused by a broad ligament internal hernia enables prompt surgical intervention and greatly aids in postoperative recovery.

The study was not supported by any sponsor or funder.

The authors declare that there are no conflicts of interest.

Mouelhi Dorsaf: Data collection, manuscript writing. Laila Jedidi; Senda ben Lahouel and Aymen Mabrouk: Critical supervision, revising manuscript. Rawia Massoudi; Briki khouloud:   resources, visualization, redaction.

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