Uncommon cause of acute intestinal obstruction

Bouchoucha Sami |

La tunisie chirurgicale - 2021 ; Vol 2021

Resumé

Acute intestinal obstruction caused by internal hernia is a rare condition. Herniation of intra-abdominal viscus through a defect in the broad ligament is uncommon and observed in 5% of all internal hernias. The preoperative diagnosis is very difficult. Abdominal CT scan allows to make the diagnosis. Surgical procedure consists of a reintegration of herniated bowel, and then closure of the ligament defect in order to prevent recurrence. Mini-invasive approach should be preferred whenever possible.

 

Mots Clés

Uncommon cause of acute intestinal obstruction

Introduction :

Acute intestinal obstruction caused by internal hernia is a rare condition. Herniation of intra-abdominal viscus through a defect in the broad ligament is uncommon and observed in 5% of all internal hernias. The preoperative diagnosis is very difficult. Abdominal CT scan allows to make the diagnosis. Surgical procedure consists of a reintegration of herniated bowel, and then closure of the ligament defect in order to prevent recurrence. Mini-invasive approach should be preferred whenever possible.

Article

Observation

 

A 61-year-old woman with no medical or surgical history who complains of  lower abdominal pain, vomiting and no stool passage since 24 hours. The patient was afebrile. Physical examination disclosed a mildly distended abdomen with tenderness. The rectal examination revealed no tarry or bloody stool. Laboratory examinations did not find an inflammation. Abdominal CT scan was performed and revealed a small bowel obstruction with a double transition zone located  
to the right of the uterus. There were no signs of intestinal necrosis, but a small amount of ascites was noted.

It is an Incarcerated hernia through board ligament. Para operatively, small bowel was found to be herniating through a narrow defect in the right broad ligament (Figure 1). Incarcerated small bowel was slightly inflammatory but not ischemic (fig. 2). The viable herniated bowel was reduced after enlargement of ligament defect. Then we perform a running suture to close the defect. Postoperative course was uneventful and the patient was discharged on the third postoperative day.

 

Fig 1 Small bowel herniated through the defect in the broad ligament as indicated in picture a. Picture b showed the defect in the broad ligament after reduction of the herniated small bowel (indicated by arrow).

 

Fig 2 Incarcerated small bowel was slightly edematous and inflammatory without necrosis.

 

 

Discussion

Acute intestinal obstruction caused by internal hernia is a rare condition. Herniation of small bowel through a defect in the broad ligament is even more uncommon and observed in 5% of all internal hernias (1,2). The preoperative diagnosis is very difficult. Defects of the broad ligament may be either acquired or congenital. In this patient the defect may be congenital because there is no surgical history or previous pelvic disease.

According the degree of broad ligament defect, hernia can be classified as fenestra type which is the most common and characterized by the presence of a defect in the two peritoneal layers. pouch type, when the defect is present in only one of the two layers. In this case herniated viscus would be trapped in the parametrial tissue and hernia-sac type when the two layers of attenuated peritoneum lines the herniated bowel, forming a true hernial sac (3).

on the other hand, there is another classification based on the location of the defect within the broad ligament. Type 1 defects occur caudal to the round ligament of the uterus. Type 2 defects occur above the round ligament. Type 3 defects occur between the round ligament and the remainder of the broad ligament, through the meso-ligamentum teres (4). we think that this classification does not have a therapeutic impact. In this case, the patient presented the broad-ligament hernia with a fenestra, Type I defect.
In case of acute intestinal occlusion the preoperative diagnosis of the occlusion mechanism is difficult. Abdominal CT scan allows to make the diagnosis by visualizing small bowel obstruction with a double transition zone located in the pelvis; a cluster of dilated small bowel loops herniated laterally to the uterus in the pelvic cavity; and enlargement of the distance between the uterus and one of the ovaries, which are deviated in opposite directions. this exam also allows to look for signs of intestinal necrosis (5,6).

By making the diagnosis preoperatively, laparoscopic approach is indicated. However, this mini invasive approach has a limit, in fact it can’t   be indicated in case of significant bowel dilatation, multiple surgical history with risk of severe adhesions or in case of counter indications of anesthetic orders.  In this case, the patient was operated by laparotomy for lack of adequate laparoscopic equipment.

Surgical procedure consists of a reintegration of herniated bowel, and then closure of the ligament defect in order to prevent recurrence.

care must be taken at the time of manipulation of the small bowel to reintegrate it. So broad ligament defect can be enlarged or completely divided (7).

 

 

Conclusion

 

The preoperative diagnosis of acute intestinal obstruction caused by internal hernia and more precisely through a broad ligament defect is very difficult.

Through this observation we would like to insist on the role of the CT scan to make the diagnosis and look for contraindications to the laparoscopic surgery.

Mini-invasive approach should be preferred whenever possible.

Références

1- Hiraiwa K, et al. Strangulated hernia through a defect of the broad ligament and mobile cecum: a case report. World J Gastroenterol 2006 ;12 :1479-1480.

 

2- Slezak FA, Schlueter TM. Hernia of the broad ligament. Hernia 1995;4:491–7.

3- Hunt AB. Fenestra and pouches in the broad ligament as an actual and potential cause of strangulated intra-abdominal hernia. Surg Gynecol Obstet 1934; 58: 906–913.

4- Cilley R, Poterack K, Lemmer J, et al. Defects of the broad ligament of the uterus. Am J Gastroenterol. 1986;81:389–91.)

5- Kosaka N, Uematsu H, Kimura H, Yamamori S, Hirano K, Itoh H. Utility of multi-detector CT for preoperative diagnosis of internal hernia through a defect in the broad ligament. Eur Radiol 2007;17:1130-3.

6- Barbier Brion, B., Daragon, C., Idelcadi, O., Mantion, G., Kastler, B. and Delabrousse, E. (2011) Small Bowel Obstruction Due to Broad Ligament Hernia: Computer Tomography Findings. Hernia, 15, 353-355.

7- Varela GG, López-Loredo A, García León JF. Broad ligament hernia-associated bowel obstruction. JSLS 2007; 11: 127–130.