Jejunal obstruction and perforation resulting from herniation through broad ligament.AS Kanbur, K Ahmed, B Bux, T Hande
Surgery Division, Burhani Charitable Trust Hospital, Anand Koliwada, Mumbra, Dist. Thane-400 612, India. , India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 11298469
Source of Support: None, Conflict of Interest: None
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.
Keywords: Abdomen, Acute, diagnosis,Anastomosis, Surgical, Broad Ligament, abnormalities,Case Report, Colectomy, methods,Female, Follow-Up Studies, Hernia, complications,diagnosis,surgery,Human, Intestinal Obstruction, diagnosis,etiology,surgery,Intestinal Perforation, diagnosis,etiology,surgery,Jejunal Diseases, diagnosis,etiology,surgery,Middle Age,
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.
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.
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, 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. 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. Incidents such as obstruction and even strangulation have been reported but these are isolated events., Tanaka et al have described a case of broad ligament hernia following surgery for obturator hernia, indicating surgical interference as an acquired cause.
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.
[Figure - 1], [Figure - 2]