Characteristics and Associated Risk Factors of Broad Ligament Hernia: A Systematic Review.

The broad ligament, also known as ligamentum latum uteri, is a double fold of peritoneum that that extends from the lateral edges of the uterus to the pelvic sidewalls. It plays a vital role in supporting the uterus and contains critical vasculature for both the uterus and adnexa. It functions alongside the cardinal ligaments, uterosacral ligaments, and pubocervical ligaments to maintain the position of the uterus in the pelvic cavity [ 1 , 2 ]. During embryological development, the paramesonephric (Müllerian) ducts fuse to become the female pelvic organs, which are subsequently enveloped by 2 layers of the peritoneum referred to as the broad ligament [ 1 ]. The broad ligament is anatomically divided into 3 subdivisions: the mesometrium: the largest portion, attaching the uterus to the sidewall and spreading laterally to cover the external iliac vessels; mesosalpinx: encloses the uterine (fallopian) tubes; and mesovarium: the posterior fold connecting the anterior surface of the ovary, which contains the ovarian vasculature within the suspensory ligament [ 3 ]. Defects of the broad ligament can result in the herniation of adjacent organs and are due to either congenital or acquired causes. Congenital causes include the rupture of cystic remnants of the paramesonephric duct, whereas acquired causes include trauma from surgery or pregnancy, endometriosis, or inflammation [ 4 ]. For example, postoperative adhesions from gynecological surgeries, such as caesarean sections, can predispose patients to broad ligament herniation (BLH) by weakening the peritoneal folds [ 5 ]. Studies have shown documented instances of BLH occurring after surgical intervention, suggesting that the mechanical stress of surgery can exacerbate or create peritoneal defects [ 6 ]. Internal hernias occur when there is a protrusion of abdominal organs into the pelvic or abdominal cavity through an orifice in the peritoneum or mesentery [ 7 ]. These conditions are relatively rare, accounting for approximately 5% of abdominal hernias, with BLH representing approximately 6% of internal hernias [ 6 , 7 ]. Etiologies include adhesions following surgery, inflammatory bowel disease, and malignancy [ 6 ]. As bariatric surgeries, such as Roux-en-Y gastric bypass, become more prevalent, the incidence of internal hernias is rising if not managed promptly [ 8 , 9 ]. Diagnosing BLH is challenging due to its rarity and nonspecific clinical presentation including abdominal pain, nausea, and vomiting [ 10 ]. Consequently, many cases are diagnosed intraoperatively, often after complications arise [ 2 ]. Delayed diagnosis can lead to increased morbidity, emphasizing the need for greater awareness of this condition among clinicians [ 4 ]. Therefore, this systematic review aims to evaluate the presentation, diagnosis, management, and factors associated with BLH. Specifically, it seeks to identify relevant patient factors, classify hernias and analyze surgical histories and the organs involved to provide a comprehensive understanding of this rare clinical presentation.

A total of 164 articles were identified from the initial search: 153 articles from PubMed and 11 articles from CINAHL. After deduplication and removal of articles based on irrelevant titles or abstracts, 45 articles were excluded. Screening for full-text retrieval in English led to the exclusion of an additional 18 articles. At the final screening stage, 41 articles were excluded because they did not provide detailed anatomical descriptions of broad ligament hernia pathology, either through imaging or surgical findings. Ultimately, 71 articles met the inclusion criteria and were included in this systematic review. A flowchart illustrating the screening and selection process is presented in Figure 1 . A total of 71 articles were included, with 6 of these reporting multiple case studies, resulting in 67 individual cases of BLH for analysis. Three main themes emerged from the review of the articles: abdominal surgical history, type of herniated organ, and classification systems. Among the 67 cases analyzed, 25 (37.3%) had a history of abdominal surgery, 33 (49.3%) did not, and 9 (13.4%) did not mention any surgical history. Of the cases with an abdominal surgical history, 14 (20.9%) also reported confirmed parity history. Across all cases, parity history was confirmed in 37 cases (55.2%), not present in 14 cases (20.9%), and unknown in 16 cases (23.9%). The age distribution of patients showed variability, ranging from under 18 to over 70 years old. The most common age group was 30–39 years, accounting for 22 cases (32.8%). The distribution was as follows: below 18 years: 1 case (1.5%); 20–29 years: 4 cases (6.0%); 30–39 years: 22 cases (32.8%); 40–49 years: 22 cases (32.8%); 50–59 years: 10 cases (14.9%); 60–69 years: 2 cases (3.0%); 70 years and older: 5 cases (7.5%); and unspecified age: 1 case (1.6%). Special consideration is warranted for older adults, particularly postmenopausal women with a history of gynecological surgeries. These individuals are at higher risk of BLH, likely due to reduced tissue elasticity and weakening of pelvic structures following procedures such as hysterectomy. This emphasizes the importance of vigilant postoperative monitoring for early detection and management of complications. In 66 cases, the herniated organ was identified. The most commonly affected organ was the intestinal tract, reported in 47 cases (71.2%), followed by the bladder in 16 cases (24.2%), and the ovaries in 3 cases (4.5%). The fenestra type of BLH was the most frequently reported, with 57 cases (86.4%). Other classifications included 1 case (1.5%) of the pouch type and 3 cases (4.5%) of the hernia sac type. Additionally, 30 cases were classified using the Cilley classification system: type 1: 20 cases (66.7%); type 2: 8 cases (26.7%); and type 3: 2 cases (6.7%). The classification systems of Cilley and Hunt are depicted in Figures 2 and 3 , respectively . Table 1 provides a summary of patient characteristics and hernia classifications, illustrating commonalities and diversity in the presentation of BLH. The findings from this review support previous studies suggesting a link between multiple pelvic surgeries and BLH. Repeated surgical interventions can weaken or create defects in the broad ligament, increasing the risk of hernia development. These findings highlight the need for clinicians to maintain a high index of suspicion for BLH in patients presenting with nonspecific abdominal symptoms, particularly those with a history of multiple abdominal surgeries.

In this systematic review, we analyzed 67 individual cases of BLH reported across 71 studies. The findings provide insights into the characteristics, classifications, and clinical presentations of BLH. Notably, 37.3% of cases had a history of abdominal surgery, while 49.3% did not, suggesting congenital and acquired etiologies [ 11 ]. The small bowel was the most commonly herniated organ, consistent with previous reports, with ileal obstruction being a frequent complication. Among classification systems, the fenestra type was the most prevalent, accounting for 86.4% of cases. These findings emphasize the importance of considering BLH in women with recurrent or non-specific abdominal symptoms, especially those with a history of gynecological or pelvic surgeries. Although BLH is rare, prompt recognition and intervention can prevent complications, such as bowel strangulation and necrosis. The results of this review align with prior research on BLH, particularly regarding the association between abdominal surgical history and hernia development. Previous reviews, such as that by Sajan et al [ 12 ], reported that 40.8% of BLH cases involved a history of abdominal surgery, a figure comparable to the 37.3% observed in the present review. Similarly, 51% of cases in our analysis were presumed congenital, mirroring findings from studies by Rohatgi et al [ 13 ] and others that highlighted the likelihood of congenital defects in the absence of surgical history [ 14 – 16 ]. The herniated organ distribution in our review is also consistent with earlier studies. The small bowel, particularly the ileum, was the most affected organ, in agreement with findings from multiple studies [ 17 , 18 ]. However, our review also highlights atypical presentations, such as the single case of urogenital symptoms reported by El Madi et al [ 19 ]. These findings emphasize the variability in clinical presentations, highlighting the need for comprehensive diagnostic approaches [ 20 ]. The classification systems developed by Hunt, as described in detail by MacDonald et al [ 21 ], and Cilley et al [ 22 ] were pivotal in understanding the anatomical variations of BLH in this review. Most cases in our analysis were categorized as fenestra type (Hunt classification) or type 1 (Cilley classification), consistent with previous literature. Holzheimer [ 23 ] highlighted the utility of such classification systems in guiding surgical approaches and standardizing reporting. Our findings support this recommendation, as consistent use of classification systems enables better understanding of BLH and facilitates future research. The findings from this review have significant implications for clinical practice. The association between prior abdominal surgeries and BLH highlights the importance of obtaining a detailed surgical history when evaluating patients with nonspecific abdominal symptoms. Additionally, healthcare providers should consider BLH as a differential diagnosis, particularly in older women or those with a history of multiple pelvic surgeries, as these individuals can have an elevated risk of hernia development. Furthermore, the variability in clinical presentations, ranging from asymptomatic cases to acute bowel obstruction, stresses the need for vigilance and thorough diagnostic imaging. Surgical teams should adopt standardized classification systems to describe hernia cases comprehensively, facilitating better communication and aiding in the development of evidence-based management strategies. Many articles lacked detailed anatomical descriptions of the hernia, resulting in their exclusion from the analysis. Additionally, some studies focused primarily on treatment procedures rather than the initial anatomical findings, limiting the scope of data available for review. Another limitation was the incomplete reporting of patient parity, with no detailed information on the number or mode of deliveries, such as vaginal versus cesarean deliveries, which could have provided a more nuanced understanding of acquired hernias. The time interval between prior surgical procedures and the development of BLH was inconsistently reported, with significant gaps in the literature regarding the pathophysiological mechanisms involved. Additionally, the lack of information on geographic location, ethnicity, and genetic predispositions prevented an analysis of potential demographic or hereditary factors associated with BLH. The paucity of reports on bilateral or recurrent BLH also limited comparisons with established baselines. Finally, limitations regarding the methods of this review include the possibility that rare cases of BLH may not always be reported in the available literature, and the exclusion of non-English articles, which could have led to the omission of relevant studies. Future research should aim to address these gaps by standardizing reporting and classification of BLH, to improve our understanding of its pathogenesis and optimal management strategies.

BLH is a rare and potentially serious condition that occurs from a weakening in one or both peritoneal folds, leading to herniation of abdominal or pelvic organs. This systematic review highlights the importance of considering the internal hernias, particularly BLH, in female patients presenting with nonspecific abdominal symptoms or intestinal obstruction. While the small bowel is the most commonly herniated organ, other organs can also be involved, potentially altering the clinical presentation. This emphasizes the need for detailed patient history and accurate classification, such as the standardized classification systems proposed by Hunt and Cilley, to enhance the understanding of this rare pathology and improve diagnostic and management strategies. In conclusion, although BLH is rare, prompt recognition and intervention can significantly reduce morbidity. Further studies using standardized classifications and detailed reporting are necessary to enhance our understanding of the prevalence, pathogenesis, and optimal management approaches of BLH.

This systematic review was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). An initial search of the literature was performed using the PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. The search terms included: “broad ligament AND hernia” and “broad ligament AND herniation” To ensure a comprehensive search, the inclusion criteria were not restricted by publication year, patient age, ethnicity, or country. This broad approach aimed to capture all relevant publications available in the databases. The inclusion and exclusion criteria for this review were predefined to ensure the relevance and quality of selected articles. The inclusion criteria were as follows: (1) case reports, (2) case series, and/or (3) articles that provided detailed anatomical description of the broad ligament herniation either through imaging findings or surgical findings. The exclusion criteria were as follows: (1) animal studies, (2) studies involving broad ligament unrelated to ligamentum latum uteri, and/or (3) articles without full-text availability in English. Descriptive analysis was performed to summarize the findings from the included studies. The presentation, diagnosis, classification, and management strategies of BLH were analyzed to identify common trends and variations.