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    • A plain abdominal radiograph showed dilatation

    2018-10-22

    A plain abdominal radiograph showed dilatation of small bowel loops filling with gas over the upper abdomen (Figure 1). Contrast-enhanced abdominal MDCT was performed, because small-bowel obstruction of a mechanical origin was suspected. The CT revealed a closed-loop dilatation of the pterostilbene located in the pelvis close to the uterus, where there was a left latero-uterine transition point. This showed mechanical occlusion of the small bowel, with an internal hernia through the left broad ligament (Figure 2). A right-forward uterine displacement and a small amount of ascites were also noted. Initial management involved aggressive fluid resuscitation for unstable hemodynamic status. A nasogastric tube was sited, which settled the patient\'s vomiting and improved her abdominal tenderness. Emergent laparotomy revealed a 15-cm-long segment of ischemic and necrotic ileum herniated through a 3 cm×3 cm defect of the left broad ligament in the posterior to anterior direction (Figure 3). As ischemic change was recognized in the incarcerated bowel, it was resected and end-to-end anastomosis was performed, and the defect of the broad ligament was closed to avoid recurrence. The postoperative period was uneventful, and the patient was discharged 9 days after surgery.
    Discussion Small-bowel obstruction is a common cause for acute surgical admission, but internal hernia through the broad ligament is a rare cause of such obstruction. In most cases, the herniated viscus through this defect is the ileum, although herniation of the colon, ovary, and ureter has also been reported. The cause of the defect in the broad ligament of the uterus may be congenital or acquired in origin. The congenital cause may be due to the rupture of congenital cystic structures, which are remnants of mesonephric or Mullerian ducts or secondary to a developmental abnormality of the peritoneum around the uterus. The acquired defects are secondary to operative trauma, inflammatory pelvic diseases, pregnancy, birth trauma, and perforations following vaginal manipulations. The defect of the broad ligament is often unilateral, but can occasionally occur bilaterally. In 19% of the cases, the defects present as bilateral defects or defects in a nulliparous woman with no prior history of abdominal surgery, trauma, or pelvic infection; in these cases, a congenital origin must be considered. Our patient previously received a lower-segment caesarean and an appendectomy, which may have contributed to the development of the broad-ligament defect. The direction throughout the defect of the broad ligament may be from the anterior to posterior direction or from the posterior to anterior direction. Hunt classified broad-ligament hernia into three categories: fenestra type, with complete fenestration from the defect in the broad ligament that permits herniation of bowel loops with strangulation potential; pouch type, with only a single anterior or posterior defect that permits bowel loops to enter and become entrapped in the parametrial tissue; and hernia-sac type, with a double layer of attenuated peritoneum covering the herniated small-bowel loops, standing for a true hernial sac. Cilley et al proposed an anatomical location-based defect classification: Type I defect, which is the most common type and occurs throughout the entire broad ligament; Type II, which corresponds to a defect through the mesovarium and mesosalpinx above the round ligament; and Type III, which corresponds to a defect through the mesoligamentum teres. Later, Fafet et al described Type IV, which corresponds to a defect involving only the mesosalpinx. In our case, the patient presented the broad-ligament hernia with a fenestra, Type I defect, with a posterior to anterior direction. Plain abdominal radiography has been used to suggest small-bowel obstruction, but is often nonspecific. Now, however, the diagnosis can be made preoperatively using MDCT. The broad ligament can be determined, because MDCT shows the round ligament contained between the two leaves of the broad ligament. The diagnostic signs of this condition include mechanical obstruction with a double beak sign located in the pelvis and the bowel loops with a C-shaped or U-shaped appearance laterally to the uterus in coronal reformations (Figure2). In our case, the CT findings of small-bowel obstruction due to broad-ligament hernia were: (1) mechanical small-bowel obstruction with a double beak sign localized in the pelvic cavity; (2) a group of dilated small-bowel loops herniated left laterally to the uterus in the pelvis, causing a right-forward uterine displacement; and (3) an enlarged distance between the uterus and one of the ovaries, which diverged in opposite directions. To the best of our knowledge, this is the first case of internal hernia through a defect of the broad ligament with dilated small-bowel loops to be preoperatively diagnosed by MDCT in Taiwan.