Laparoscopic repair of a small bowel herniation through a broad ligament defect.

A 44-year-old female presented with a diagnosis of intestinal obstruction from unknown origin. Laparoscopy revealed herniation of small bowel trough a defect in the left broad ligament. After reduction, the defect was corrected laparoscopically. The post operative recovery was uneventful.

Internal herniation accounts for only 1% of all intestinal obstructions.[1] Herniation through a defect in the broad ligament remains an uncommon cause of intestinal obstruction, accounting for about 5% of internal hernias.[2] It was first reported in an autopsy series in 1861 by Quain. There are few cases where the defect has been repaired laparoscopically.

We report the case of a 44-year-old female whose medical history included four normal pregnancies (3 had been delivered vaginally and 1 by caesarean section). She presented with a 48-hour small bowel obstruction. Clinical examination revealed abdominal distension with moderate lower abdominal pain and increased bowel sounds. Pelvic and rectal examinations were unremarkable. Laboratory findings showed leucocytosis (21,800 WBC) and a plain abdominal radiograph showed loops of dilated small bowel with air fluid levels. An abdominal computed tomography (CT) revealed a small bowel transition area at minor pelvis with parietal thickening and free fluid [Figure 1].

Figure 1

CT: a) small bowel distension and b) small bowel transition area at minor pelvis

Laparoscopic exploration was performed. The approach was made with three trocars (one of 10 mm and two of 5 mm). A loop of small intestine was noted to be herniating through a defect in the broad ligament [Figure 2a and b]. The small bowel was reduced with blunt manoeuvres with vital appearance and no resection was required. The defect was about 3 cm. and it was repaired laparoscopically with a single stitch of 2-0 multifilament absorbable suture [Figure 2c and d].

Figure 2

(a) Laparoscopic reduction of the hernia. Broad ligament exposure (Type III defect). (b) Broad ligament defect (fenestra morphology). (c and d) Laparoscopic repair

The post operative recovery was uneventful and the patient was discharged 48 hours after the procedure.