An unexpected twist in bowel obstruction: a case report.

A 34-year-old female presented with acute, severe, colicky, generalized abdominal pain accompanied by a single episode of vomiting. The patient reported obstipation, preceded by intermittent constipation over the past week. She had no comorbidities but a surgical history of two cesarean sections and a prior dilatation and curettage. On examination, she was tachycardic with generalized abdominal tenderness, distension, and rigidity. Routine blood investigations were within normal limits. Abdominal radiography revealed dilated small bowel loops with multiple air-fluid levels. Abdominal contrast-enhanced CT revealed dilated jejunal and proximal ileal loops, mild bowel wall thickening, minimal peritoneal fluid, and interloop mesenteric haziness, suggestive of an infective or adhesive etiology ( Fig. 1A ). However, no definitive mechanical cause was identified. The patient underwent an emergency diagnostic laparoscopy. Intraoperative evaluation revealed a closed-loop obstruction caused by a segment of small bowel herniating through a 5-cm defect in the left broad ligament. The bowel was viable and carefully reduced. The defect was closed using continuous sutures with 3-0 polygalactin sutures ( Fig. 2 ). No contralateral defects were identified. The patient was mobilized on postoperative day (POD) 0 and initiated on an oral liquid diet after passing flatus on POD 1. The postoperative course was uneventful.

Internal hernias are rare and account for a small proportion of small bowel obstructions. The broad ligament, a paired fold of peritoneal reflection that extends from the sides of the uterus to the lateral pelvic walls and encloses structures such as the fallopian tubes and ovaries, rarely serves as a site for internal herniation. Broad ligament hernias (BLHs) are among the rarest types, representing only 4%–7% of internal hernias. BLH occurs when a defect in the broad ligament permits herniation of intra-abdominal organs [ 1 ]. Its clinical presentation often mimics other causes of bowel obstruction, leading to delayed diagnosis. Abdominal computed tomography (CT) is essential for evaluating internal hernias [ 2 ], although BLH defects are often subtle and easily missed. Diagnostic laparoscopy is not considered the standard for definitive diagnosis and management [ 3 ]. Herein, a case of small bowel obstruction due to a left-sided BLH, successfully treated by laparoscopic reduction and defect closure, has been reported.

BLH is a rare cause of small bowel obstruction, accounting for approximately 4% to 7% of internal hernias [ 4 ]. First described by MacDonald et al. [ 1 ], the first surgical repair was reported by Grey in 1933. Diagnosis is frequently delayed due to nonspecific clinical features and subtle imaging findings, increasing the risk of strangulation and ischemia. CT is the preferred imaging modality for evaluating internal hernias [ 2 ]; however, BLHs are frequently overlooked due to their subtle radiologic features. In this case, CT showed dilated bowel loops and a band-like structure in the pelvis suggestive of obstruction but did not clearly reveal the internal herniation defect. In retrospect, the presence of dilated bowel loops located caudal to a displaced uterus was a subtle but important clue that could have suggested a BLH preoperatively. BLHs are commonly classified according to the criteria proposed by Hunt and Cilley ( Fig. 1 ). According to Hunt’s classification, BLHs are divided into two types. The fenestra type involves fenestration of both peritoneal layers, whereas the pouch type involves a defect in a single peritoneal layer, forming a pouch [ 5 ]. According to Cilley’s classification, BLHs are divided into three types. Type I is a defect below the round ligament (remnant of the distal gubernaculum, extending from the uterine cornua through the inguinal canal to the labia majora). Type II is a defect above the round ligament involving the mesosalpinx or mesovarium. Type III is a defect between the round ligament and the remainder of the broad ligament [ 6 ]. Our patient had a type I, fenestra-type defect. The etiology of BLHs might be congenital or acquired. Congenital defects result from developmental anomalies of the broad ligament, whereas acquired defects are associated with trauma, prior surgery, pregnancy, endometriosis, or pelvic inflammatory disease [ 7 ]. In this case, the patient’s history of cesarean sections likely contributed to an acquired defect. Laparoscopy is the preferred surgical approach for BLH, offering diagnostic and therapeutic benefits with minimal invasiveness [ 8 ]. Intraoperatively, both broad ligaments should be examined, as multiple defects have been reported in up to 20% of cases [ 7 ]. For large defects or when tissue integrity is compromised, reinforcement with omental patches might be necessary. A review of recently published cases of BLH is summarized in Table 1 , and the corresponding references can be found in Supplementary Material 1 . Although rare, BLHs should be considered in the differential diagnosis of small bowel obstruction in females, particularly when routine imaging fails to reveal a definitive cause. Early diagnostic laparoscopy facilitates confirmation of the diagnosis and immediate treatment, resulting in improved outcomes and reduced recovery time [ 9 ].