Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 46, Num. 3, 2000, pp. 189-190

Journal of Postgraduate Medicine, Vol. 46, No. 3, July-September, 2000, pp. 189-190

Case Report

Jejunal Obstruction and Perforation Resulting From Herniation Through Broad Ligament

Kanbur AS, Ahmed K, Bux B, Hande T

Surgery Division, Burhani Charitable Trust Hospital, Anand Koliwada, Mumbra, Dist. Thane - 400 612, India.
Address for correspondence: Ajay Kanbur, MCh, Shivneri Hospital, Agra Road, Thane - 400 602, India. E-mail: ajaykanbur@mantraonline.com

Code Number: jp00068

Abstract:

Internal herniation of small bowel through broad ligament causing obstruction is rare. A case of jejunal herniation through broad ligament defect with resultant obstruction and perforation is presented. (J Postgrad Med 2000; 46:189-190)

Key words: Jejunum, Broad ligament, hernia

Incidence of small bowel obstruction due to internal herniation is rare and accounts for about 1% of acute obstructions. Broad ligament defects can cause small bowel to herniate through them, which in turn lead to complications like obstruction, strangulation or perforation. This is a rare cause to be borne in mind in a female patent with intestinal obstruction.

Case report

A 48 year old female patient, with known history of mitral valve prolapse with regurgitation, but otherwise in good health, was admitted with severe lower abdominal pain, nausea and vomiting of acute onset. There was no history of fever, trauma, vaginal or abdominal operations. She was postmenopausal and had two normal deliveries.

On examination, her vital parameters were normal. Abdomen was marginally distended and there was slight tenderness at umbilicus. Digital rectal examination and per vaginal examinations were normal. Hyperperistalsis was present. She also had a murmur consistent with mitral valve regurgitation. On admission, all haematological and biochemical investigations were normal. Plain x-ray abdomen in standing position showed dilated loops of jejunum in left upper quadrant with no air fluid levels. Ultrasound of abdomen revealed no abnormality except dilated bowel loops without free fluid in abdomen.

Initially she received conservative line of treatment with naso-gastric decompression, intravenous fluids and antibiotics. Forty-eight hours later, she developed obstipation; her pain worsened and she had tachycardia. Rectal tenderness was present with ballooning suggestive of obstruction. Repeat plain x-ray abdomen standing showed further distension of gas filled loops with air fluid levels but no free air under diaphragm. Water soluble contrast follow through was obtained through the nasogastric tube, which showed dilated jejunum with complete obstruction but no perforation. Facility for computed tomography scan was not available in our setting. A clinical diagnosis of jejunal obstruction was made.

At exploration, the mid-jejunum had herniated through a narrow defect in the left broad ligament causing obstruction and perforation (Figure 1). There was little peritoneal contamination indicating recent perforation. Local resection of jejunum was performed. Defect was below the round ligament but above major uterine vessels (Figure 2). This was closed in vicryl sutures. Patient had an uneventful recovery.

Discussion

Small bowel obstruction due to internal herniation is rare. Common causes are adhesions, strangulated inguinal hernias and neoplasms. Even rare is the herniation through broad ligament defects. The earliest reported case of herniation of bowel through a defect in broad ligament of uterus was by Slezak,¹ found at autopsy.

Broad ligament defects are classified as being congenital or acquired. Congenital causes have an embryological basis due to developmental defect in supports of the uterus. Acquired ones are due to previous surgery, trauma during delivery, perforations following vaginal manipulations and pelvic inflammatory disease. A classification of broad ligament defects has been proposed based on the anatomical position of the defect.² Type I - defect caudal to round ligament; type II - defect above broad ligament; and type III - between round ligament and remainder of broad ligament, through meso-ligamentum teres.

There have been few reports of bowel herniating through broad ligament.³ Incidents such as obstruction and even strangulation have been reported but these are isolated events.^4,5 Tanaka et al have described a case of broad ligament hernia following surgery for obturator hernia, indicating surgical interference as an acquired cause.⁶

Early diagnosis of such cases need high index of suspicion, particularly in female patients who present with small bowel obstruction and have no history of operations in the past. Though plain x-ray abdomen and ultrasound give a clue, the accuracy in pinpointing the cause lies with computed tomography scan, as is exemplified by Suzuki et al.⁷

References

1. Slezak FA, Schlueter TM. Hernia of the broad ligament of the uterus. In: Nyhus LM, Codon RE, editors. Hernia. 3^rd Edition. Philadelphia: J. B. Lippincott; 1989. pp 311-316.
2. Cilley R, Poterack K, Lemmer J, Dafoe D. Defects of the broad ligament of the uterus. Am J Gastroenterol 1986; 81:389-391.
3. Cleator IG, Bowden WM. Bowel herniation through a defect of the broad ligament. Br J Surg 1972; 59:151-153.
4. Simstein NL. Internal herniation through a defect in the broad ligament. Am Surg 1987; 53:258-259.
5. Ishihara H, Terahara M, Kigawa J, Terakawa N. Strangulated herniation through a defect of the broad ligament of the uterus. Gynecol Obstet Invest 1993; 35:187-189.
6. Tanaka M, Kaneko Y, Ietsugu K, Yoshida C. Internal herniation through a broad ligament defect after obturator hernia repair. Surg Today 1994; 24:634-637.
7. Suzuki M, Takashima T, Funaki H, Uogishi M, Isobe T, Kanno S, et al. Radiologic imaging of herniation of the small bowel through a defect in the broad ligament. Gastrointest Radiol 1986; 11:102-104.

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