J Radiol Sci 2011; 36: 125-128
Internal Hernia Through A Defect of Broad ligament
Kwok-Wan Yeung1 Ming -Sung Chang2 Pai-Tsung Chiang2
Departments of Radiology1 and Surgery2, Fooyin University Hospital, Pingtung, Taiwan
ABSTRACT
Internal hernia is a rare cause of small bowel loop obstruction. Hernia through a defect of the broad ligament is
extremely rare. A female patient who had received laparoscopic oocyte retrieval 20 years ago suffered from intermittent lower abdominal cramping pain and vomiting. Internal hernia through the defect of the broad ligament is
confirmed through a series of imaging studies and surgical exploration. To the best of our knowledge, this is the first
case of internal hernia through a defect of the broad ligament in which the small bowel loop inside the herniated sac is
collapsed rather than dilated, as noted on the computed tomography and surgical finding.
Internal hernia is a rare cause of intestinal obstruction, accounting for 1% of all intestinal obstructions [1-9].
Hernia through defects of broad ligament is even rarer,
accounting for only 4% to 5% of all internal hernias. It may
cause close-loop obstruction or even strangulation [10-12].
Most of the cases of internal hernia revealed dilated herniated bowel loops [1-12]. Only a few cases showed collapsed
bowel loops inside the herniated sac, signifying incomplete
obstruction of the efferent loops [13-15]. We now present
the imaging findings of a case of internal hernia through a
defect of the broad ligament.
CASE REPORT
A 58 year-old female patient suffered from intermittent
lower abdominal cramping pain and vomiting for 2 days.
Tracing her past history, she received laparoscopic oocyte
retrieval half year apart for two times 20 years ago. Physical
examination was unremarkable. Blood analysis revealed
WBC = 11540/μl (neutrophils = 85.5%, lymphocytes =
9.5%). The other biochemical blood data and urine analysis
were within normal limit.
A series of imaging studies was performed. Supine
and standing KUB revealed distended small bowel loop in
the middle abdomen (not shown). Abdominal sonography
showed fluid-filled small bowel loop associated with ascites
in the pelvic cavity (not shown). Abdominal computed
tomography (CT) was performed using a 64-detector row
multi-detector CT (MDCT, Brilliance CT 64-channel by
Philips Medical Systems, Netherlands). Contrast-enhanced
CT with axial images and reformatted coronal and sagittal
images showed small intestinal dilatation with a transition
point at ileum, just lateral to the left aspect of the uterus.
(Fig. 1). Rightward displacement of the uterus and right
dorsal displacement of the rectosigmoid colon were seen.
The air content inside the efferent loop implies a partial
obstruction of the ileal loop. These findings were consistent
with internal hernia through a defect of the left broad
ligament.
Emergent exploratory laparotomy uncovered a segment
of ileum herniated through a 3 × 3 cm 2 defect of the left
broad ligament from posterior to the anterior direction
(Fig. 2). The involved ileum showed ischemic change but
became revascularized again after pressure relief. Repair of
the defect was performed. No bowel infarction was noted.
Correspondence Author to: Kwok-Wan Yeung
Department of Radiology, Fooyin University Hospital, Pingtung, Taiwan
No. 5, Chung-Shan Road, Tung-Kang, Pingtung 928, Taiwan
J Radiol Sci June 2011 Vol.36 No.2
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Internal hernia through a defect of broad ligament
Figure 1
1a
1b
1d
1e
1c
Figure 1. Axial contrast-enhanced MDCT images with two sequential axial planes (a is 1cm cranial to b) reveal a defect in
the left broad ligament with twisted ileal loop (black arrow in a), the dilated afferent ileum (thick white arrow in b) with a
beak sign (black arrow in b), the collapsed herniated loop (thin white arrows). Right dorsal displacement of the rectosigmoid
colon (curve arrow) and rightward displacement of the uterus (U) are found. Reformatted coronal images (d is 4cm anterior
to c) and sagittal images (e) are obtained. The defect has a diameter of 2.5cm (between the black arrows in c). Note the nondilated ileal loops clustered inside the herniated sac (the white arrows in d and e).
DISCUSSION
Internal hernia is a rare cause of small bowel loop
obstruction and accounts for about 1% of all intestinal
obstruction [1-6]. Hernia through a defect of the broad ligament is extremely rare and constitutes less than 7% of all
internal hernias. The ileum is most commonly involved.
Herniation of colon, ovary and ureter has also been
described [3].
The etiologies may be congenital or acquired [1-8].
Congenital defects are the result of a developmental defect
in the broad ligament. Acquired causes consists of prior
surgery (as in our case), perforation following vaginal
manipulation, trauma (including birth trauma) and pelvic
inflammatory disease. Low body mass index may be a
126
contributory factor because it may lead to a very thin
mesoovarium and mesosalpinx and cause the patient more
prone to a rupture of the broad ligament, with resultant
bowel herniation through this defect [7].
The defect of the broad ligament may be unilateral but
may occasionally occur bilaterally [2, 4]. Hunt et al defined
two types of internal herniation through the broad ligament
[9]: the fenestra type that involves the anterior and posterior
leaves of the broad ligament and the pouch type in which
the defect involves one layer of the anterior or posterior leaf.
The more common fenestra type has the complete defect
and may allow passage of the small bowel loop and cause
potential strangulation of the herniated bowel loop [8]. The
defect in our case was of the fenestra type but no bowel
ischemia was noted after reduction. The pouch type having
J Radiol Sci June 2011 Vol.36 No.2
Internal hernia through a defect of broad ligament
Figure 2
Figure 2. Exploratory laparotomy
reveals a defect in left broad ligament
between the uterus (U) and left ovary
(O).
single-layer defects may cause the bowel loop to enter and
entrapped in the parametrial tissue.
The direction through the defect of the broad ligament
may be from posterior to anterior [2] (as in the present case)
or from anterior to posterior direction [6]. The CT appearance in the former condition shows the herniated loop on the
left upper side of the uterus, causing rightward deviation of
the uterus. In the anterior-to-posterior herniation, the bowel
loop herniates into the pouch of Douglas causing ventral
displacement of the uterus and dorso-lateral deivation of the
rectosigmoid colon. In both directions, a cluster of dilated
small bowel loops with air-fluid levels may be present.
Hernia through a defect of the broad ligament may
cause closed-loop obstruction (incarceration) or even strangulation (ischemia) [3, 10-12]. Several CT signs may confirm
closed-loop obstruction. The incarcerated small bowel loop
shows radial distribution with stretched mesenteric vessels
converging toward the point of torsion. The dilated bowel
loop has U-shaped or C-shaped appearance. At the site
of torsion, the dilated loop may show a “beak” sign as a
fusiform tapering of the bowel loop imaged in longitudinal
section.
Although many internal hernias cause dilatation of
the incarcerated bowel loop, some remains nondilated
and shows a cluster of collapsed small bowel loops inside
the herniated sac [13-15], such as a left-side paraduodenal
hernia [13], internal hernia through a peritoneal defect of
the pouch of Douglas [14] and herniation through a defect of
the broad ligament (as in our case). The collapsed herniated
J Radiol Sci June 2011 Vol.36 No.2
bowel loops implied incomplete obstruction of the efferent
loop [14]. To the best of our knowledge, this is the first case
of internal hernia through a defect of the broad ligament
with the collapsed (rather than dilated) small bowel loop
inside the herniated sac, as noted on the computed tomography and verified during surgical exploration.
In conclusion, internal hernia through a defect of
broad ligament is a very rare form of all internal hernias.
Preoperative recognition and specific CT characteristics of
this rare form of internal hernia prompt emergent operation
and reduce the mortality and morbidity of the patient.
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