{"paper_id":"b2e1bf63-ebc3-43f6-84dc-7ae2d31ad426","body_text":"ORIGINAL ARTICLE\nReceived: 6 December 2014 / Accepted: 26 May 2015 / Published online: 9 June 2015\n# Springer-V erlag Berlin Heidelberg 2015\nAbstract We report a case of a woman with chronic right-\nsided pelvic pain with an unusual combination of broad liga-\nment defects and associated terminal ileum and caecum her-\nniation. Reduction of the hernia and closure of the defects at\nlaparoscopy resulted in resolution of the patient ’s painful\nsymptoms. Review of the literature suggests that, although\nrare, such defects should be considered in the differen-\ntial diagnosis of persistent pelvic pain. Where found\nincidentally, broad ligament defects should be repaired in or-\nder to prevent sinister complications such as bowel obstruc-\ntion and strangulation.\nKeywords Chronic pelvic pain . Broad ligament defect .\nLaparoscopy . Bowel herniation\nIntroduction\nHerniation of a viscus through a defect of the broad ligament\nof the uterus is a rare form of internal hernia [ 1]. This type of\nhernia is difficult to diagnos e preoperatively due to the\nnon-specific nature of sympt oms and limitations of im-\naging [ 2]. We report a case of chronic pelvic pain with\na diagnosis of bowel herniation through a right-sided\nbroad ligament fenestration and its subsequent laparoscopic\nmanagement. We review the literature and present our conclu-\nsions and recommendations on the diagnosis and management\nof this condition.\nCase report\nA 36-year-old woman (one previous vaginal delivery) pre-\nsented at our outpatient gynaecology clinic with chronic,\nnon-cyclical, intermittent, right-sided pelvic pain and associ-\nated bloating. In addition, she reported dysmenorrhoea and\noccasional dyspareunia.\nAn initial diagnostic laparoscopy was performed, where\nthe peritoneal defects were seen (right-sided broad ligament\nfenestration and a fenestration underneath the right uterosacral\nligament), but there was no herniation at the time and no\ncorrective measures were taken. Thereafter, a number of med-\nical treatments were tried for her pains including contraceptive\npills, the levonorgestrel-releasing intrauterine system and\ngonadotrophin-releasing analogues with add-back hormone\nreplacement treatment. Whilst these treatments improved her\ndysmenorrhoea, she still continued to get intermittent pains\nand bloating. The patient described these pains as non-cycli-\ncal, occasionally stabbing and occasionally colicky. The fre-\nquency of the pains varied in a given month with several pain-\nfree days and several random episodes of pain in a given day,\nat times with gradual onset, other times with acute onset. A\nsigmoidoscopy, barium enema and CT scan were performed\nand showed normal findings.\nThree years following her initial presentation, a second\nlaparoscopy was performed due to persistent pains. The cae-\ncum and terminal ileum were seen to be herniating through a\nlarge (approximately 6 cm) right-sided broad ligament fenes-\ntration. There was no evidence of bowel ischaemia or necro-\nsis. The hernia was reduced by gently manipulating the bowel,\nassisted by the Trendelenburg position, and the defects were\ncarefully mapped. A further fenestration was identified under-\nneath a deficient right uterosacral ligament (Fig.1). The broad\nligament defect was closed using a continuous 2 –0 Polysorb\nsuture with intra-corporeal knotting. The right uterosacral\n* Va s i le i o s M i n a s\nbillminas@gmail.com\n1 Minimal Access Centre, Department of Obstetrics and Gynaecology,\nWirral University Teaching Hospital, Merseyside, UK\nGynecol Surg (2015) 12:275–277\nDOI 10.1007/s10397-015-0898-0\nBroad ligament defects as a cause of chronic pelvic pain\nCharlotte Palmer1 & David Rowlands1 & Vasileios Minas1\n\nligament was transected to prevent any future bowel hernia-\ntion. Repair of this defect by suturing was not deemed sensible\nas the deficient ligament was too thin. No other pelvic pathol-\nogy was seen. Six months later, the patient reported complete\nresolution of her symptoms.\nDiscussion\nHerein, we present a case of intestinal herniation through a\nlarge broad ligament defect, repair of which resolved the\nchronic painful symptoms of the patient. Such hernias repre-\nsent 4 –7 % of all internal hernias [ 3]. The most common\nviscus to herniate is the ileum, however, colonic and ovarian\nherniation have also been reported [3–5]. Broad ligament de-\nfects were first documented in the literature in 1861 following\na post-mortem on a woman who died from intestinal obstruc-\ntion [1]. She was found to have a strangulated bowel in a right-\nsided broad ligament fenestration.\nThe precise pathogenesis of broad ligament defects remains\nunknown. They tend to be unilateral, more commonly on the\nright side and are thought to be either congenital or acquired\n[3]. Congenital defects may be related to ruptured cystic struc-\ntures reminiscent of the mesonephric or paramesonephric ducts\nduring embryological life [3 ]. Acquired or secondary causes\nmay include previous surgery, previous pregnancy, pelvic in-\nflammatory disease and endometriosis. Preoperative diagnosis\nis difficult if not impossible. Whilst computed tomography can\nbe useful in identifying acute ly dilated bowel in cases where\nherniation has resulted in bowelobstruction, it is very difficult\nto pinpoint accurately the broad ligament as the site of internal\nhernia with incarceration [2].\nTwo systems for characterising broad ligament defects\nhave been described in the literature. In 1934 Hunt et al.\nc a t e g o r i s e dd e f e c t sb a s e do nthe nature of the deficiency\n(complete versus incomplete fenestrations) [ 6], whereas in\n1986, Cilley et al. created a more commonly used classifica-\ntion system based on anatomical position [ 1]. According to\nCilley et al., type I defects are the most common and occur\nthroughout the entire broad ligament caudal to the round lig-\nament. Type II defects occur superior to the round ligament,\nincluding defects in the infundibulopelvic ligament,\nmesosalpinx and ovarian ligament. Type III defects occur in\nthe two layered peritoneal surface between the round ligament\nand the remainder of the broad ligament. In our case, we\ndiagnosed type II and type III defects with an unusual combi-\nnation of a defect underneath a thin right uterosacral ligament.\nThe majority of literature reporting such defects relates to\nacute presentations of abdominal pain and visceral incarcera-\ntion, most commonly bowel obstruction [ 6–10]. Our search\nreturned 39 cases of bowel herniation through broad ligament\ndefects with associated obstruction. The reports date from\n1965 to 2014. Although it is beyond the scope of our present\npaper to cite all these publications, it is interesting to note that\nin 6 of these cases, preoperative diagnosis was possible by\nmulti-detector computed tomography (MDCT, high resolution\ncomputed tomography) [2, 11–15]. Barbier Brion et al. sug-\ngest that MDCT can demonstrate the presence and the precise\nlocation of this type of hernia and that this may assist clini-\ncians approach the problem laparoscopically rather than by\nexplorative laparotomy [14]. Eight out of the 39 cases were\nmanaged by laparoscopy and the rest 31 by laparotomy.\nOur case highlights a more chronic course of pelvic pain\nassociated with broad ligament defects. Three published cases\nFig. 1 a Caecum herniating\nthrough the right broad ligament\ndefect, b right broad ligament\ndefect as seen after the hernia was\nreduced, c right uterosacral\nligament fenestration, and d\nrepair of defect by continuous\nlaparoscopic suture and intra-\ncorporeal knotting. c caecum, s\nuterosacral ligament, u uterus, r\nround ligament, f fallopian tube, i\ninfundibulopelvic ligament\n276 Gynecol Surg (2015) 12:275–277\n\nexist, whereby chronic pain was considered to be associated\nwith broad ligament defects [ 3, 16, 17]. Redwine reported a\ncase of a woman diagnosed with endometriosis affecting the\nbroad ligament and treated laparoscopically by fulguration\n[16]. The symptoms of the patient persisted and at repeat\nlaparoscopy the small bowel and the caecum were seen her-\nniating through a broad ligament defect. The defect was\nrepaired and the patient ’s pains resolved. The author sug-\ngested that the defect was a result of the electrocoagulation\napplied to treat endometriosis. Similarly, Demir and Scoccia\ndescribed a case of chronic pelvic pain resistant to medical and\nsurgical treatments for endometriosis. A broad ligament defect\nwas diagnosed at laparoscopy and left untreated. At subse-\nquent laparoscopy the ovary was seen to be herniating through\nthe defect. A unilateral salpingo-oophorectomy was per-\nformed, the defect was eliminated and the patient’ss y m p t o m s\nresolved\n3. Bangari and Uchil reported herniation of small in-\ntestine through a large right-sided broad ligament defect, this\ntime with no associated endometriosis, suturing of which\ncured the patient’s chronic pelvic pain [17]. Of note, no com-\nplications were reported as a result of repair of broad ligament\ndefects in any of the papers we reviewed describing either\nacute or chronic presentations.\nSimilarly, with complete symptom resolution following\nlaparoscopic repair, we believe the most likely cause of our\npatient’s pain was intermittent herniation of bowel through the\ndefect. We therefore strongly support the suggestion by\nBangari and Uchil [ 17]a n dD e m i ra n dS c o c c i a[3], of\nrepairing or eliminating any incidental broad ligament defects\nfound at laparoscopy. This may not only prove curative for the\npatient’s painful symptoms, but also prevent future sinister\ncomplications such as bowel obstruction and strangulation,\nand/or repeated surgical intervention due to persistent pain.\nConclusion\nInternal hernias through a broad ligament defect, though rare,\nshould be considered in the differential diagnosis of women\npresenting with chronic pelvic pain, particularly when this is\nright-sided. This is further relevant in cases where routine\ninvestigations have failed to identify pathology and/or routine\ntreatments have failed to relieve symptoms. Laparoscopic\nmanagement can be both diagnostic and therapeutic, and we\nrecommend that repair by suturing ideally be carried out at\ninitial identification, even if no herniation is seen at the time.\nCompliance with ethical standards All procedures followed were in\naccordance with the ethical standards of the responsible committee on\nhuman experimentation (institutional and national) and with the Helsinki\nDeclaration of 1975, as revised in 2008.\nInformed consent was obtained from all patients for being included in\nthe study.\nAuthors’ contribution C. Palmer collected the data and wrote the\nmanuscript. D. Rowlands was responsible for project development. V .\nMinas also wrote the manuscript and edited it.\nConflict of interest On behalf of all the authors, the corresponding\nauthor states that there is no conflict of interest.\nReferences\n1. Cilley R, Poterack K, Lemmer J, Dafoe D (1986) Defects of the\nbroad ligament of the uterus. Am J Gastroenterol 81:389–391\n2. Quiroga S, Sarrias M, Sanchez JL, Rivero J (2012) Small bowel\nobstruction secondary to internal hernia through a defect of the\nbroad ligament: preoperative multi-detector CT diagnosis. Abdom\nImaging 37:1089–1091\n3. Demir H, Scoccia B (2010) Internal herniation of adnexa through a\ndefect of the broad ligament: case report and literature review. J\nMinim Invasive Gynecol 17:110–112\n4. Langan RC, Holzman K, Coblentz M (2012) Strangulated hernia\nthrough a defect in the broad ligament: a sheep in wolf ’s clothing.\nHernia 16:481–483\n5. Lo K, Lie K (2013) Internal herniation through a broad ligament\ndefect found at laparoscopy. J Obstet Gynaecol Can 35:401–402\n6. Hunt AB (1934) Fenestra and pouches in the broad ligament as an\nactual and potential cause of strangulated intra-abdominal hernia.\nSurg Gynecol Obstet 58:906–913\n7. Garcia-Oria M, Inglada J, Domingo J et al (2007) Small bowel\nobstruction due to broad ligament hernia successfully treated by\nlaparoscopy. J Laparoendosc Adv Surg Tech A 17:666–668\n8. Hiraiwa K, Morozumi K, Miyazaki H, Sotome K, Furukawa A,\nNakamaru M (2006) Strangulated hernia through a defect of the\nbroad ligament and mobile caecum: a case report. World J\nGastroenterol 12:1479–1480\n9. Onida S, Lynes K, Ozdemir BA, Whitehouse PA (2010)\nUnexpected findings at diagnostic laparoscopy: caecal incarcera-\ntion with concurrent appendicitis in a patient with bilateral broad\nligament defects. Ann R Coll Surg Engl 92:W19–20\n10. Agresta FM, Nucgeket I, Candiotto E, Bedin N (2007) Incarcerated\ninternal hernia of the small intestine through a breach of the broad\nligament: two cases and a literature review. JSLS 11:225–227\n11. Kosaka N, Uematsu H, Kimura H, Y amamori S, Hirano K, Itoh H\n(2007) Utility of multi-detector CT for pre-operative diagnosis of\ninternal hernia through a defect in the broad ligament. Eur Radiol\n17:1130–1133\n12. Matsunami M, Kusanagi H, Hayashi K, Y amada S, Kano N (2014)\nBroad ligament hernia successfully treated by laparoscopy: case\nreport and review of literature. Asian J Endosc Surg 7:327–329\n13. Chapman VM, Rhea JT, Novelline RA (2003) Internal hernia\nthrough a defect in the broad ligament: a rare cause of intestinal\nobstruction. Emerg Radiol 10:94–95\n14. Barbier Brion B, Daragon C, Idelcadi O, Mantion G, Kastler B,\nDelabrousse E (2011) Small bowel obstruction due to broad liga-\nment hernia: computed tomography findings. Hernia 15:353–355\n15. Mailleux P , Ramboux A (2010) Small bowel obstruction due to an\ninternal herniation through a defect of the broad ligament. JBR-\nBTR 93:201–203\n16. Redwine DB (1989) Symptomatic internal hernia of the broad lig-\nament: a complication of electrocoagulation of endometriosis.\nObstet Gynecol 73(part 2):495–496\n17. Bangari R, Uchil D (2012) Laparoscopic management of internal\nhernia of small intestine through a broad ligament defect. J Minim\nInvasive Gynecol 19:122–124\nGynecol Surg (2015) 12:275–277 277","source_license":"CC0","license_restricted":false}