Laparoscopic Management of Strangulated Broad Ligament Hernia

Copyright © 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http:// creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1.Introduction Internal hernias occur when there is a protrusion of the viscera through the peritoneum or mesentery within the peritoneal cavity. The most common type is paraduodenal hernia.1 Broad ligament hernias (BLH) make up 4%-5% of all internal hernias. Broad ligament (BL) defects still pose questions of how to diagnose and manage them. The first report of a broad ligament hernia was made post-autopsy by Quain in 1861, and a 1995 review article indicated only 61 cases have ever been reported.2 Defects have been broadly suggested to be congenital or acquired in origin. The typical patient in the literature was a middle-aged, multi-parous (85% of cases) woman with no abdominal surgery.3 BLH is one differential diagnosis of intestinal obstruction and those presenting with ileus. BLH are generally difficult to diagnose because of their tendency to cause nonspecific symptoms such as nausea, vomiting, and abdominal pain. Therefore, these hernias are often found in exploratory laparotomy or diagnostic laparoscopy. In more recent years, diagnosis pre-surgically by computed tomography (CT) has been considered, as with CT, it is possible to confirm the hernia’s nature and location, obstruction, and type.4 However, more often than not, BLH are confirmed by surgical means. It has been suggested that a CT scan could be diagnostic when showing incarceration of a dilated intestinal loop in the Douglas pouch with air fluid levels.5 BL defects are usually found unilaterally and, if diagnosed pre-operatively with the absence of intestinal damage, they are often managed laparoscopically and have the benefits of minimal access surgery. The objective of this paper is to report the successful minimal access management of a BL strangulated hernia. Abstract


1.Introduction
Internal hernias occur when there is a protrusion of the viscera through the peritoneum or mesentery within the peritoneal cavity.The most common type is paraduodenal hernia. 1 Broad ligament hernias (BLH) make up 4%-5% of all internal hernias.Broad ligament (BL) defects still pose questions of how to diagnose and manage them.The first report of a broad ligament hernia was made post-autopsy by Quain in 1861, and a 1995 review article indicated only 61 cases have ever been reported. 2Defects have been broadly suggested to be congenital or acquired in origin.The typical patient in the literature was a middle-aged, multi-parous (85% of cases) woman with no abdominal surgery. 3BLH is one differential diagnosis of intestinal obstruction and those presenting with ileus.
BLH are generally difficult to diagnose because of their tendency to cause nonspecific symptoms such as nausea, vomiting, and abdominal pain.Therefore, these hernias are often found in exploratory laparotomy or diagnostic laparoscopy.In more recent years, diagnosis pre-surgically by computed tomography (CT) has been considered, as with CT, it is possible to confirm the hernia's nature and location, obstruction, and type. 4However, more often than not, BLH are confirmed by surgical means.It has been suggested that a CT scan could be diagnostic when showing incarceration of a dilated intestinal loop in the Douglas pouch with air fluid levels. 5BL defects are usually found unilaterally and, if diagnosed pre-operatively with the absence of intestinal damage, they are often managed laparoscopically and have the benefits of minimal access surgery.The objective of this paper is to report the successful minimal access management of a BL strangulated hernia.

Case Presentation
A 35-year-old fit and healthy female presented with a history of 6 hours of acute lower abdominal pain, nausea, and vomiting.She had no significant past medical, surgical, or gynecological history.Clinical examination showed a heart rate of 85 beats per minute; normal temperature, blood pressure, and respiratory rate; a mildly distended abdomen with tenderness across the right lower quadrant; and normal examination of pelvic and hernial orifices.A plain abdominal X-ray showed dilated small bowel loops.Blood test showed leukocytosis (white blood cells were 17000 × 10 9 /L).Urgent diagnostic laparoscopy showed a broad ligament strangulated hernia with small bowel infarction.Reduction of the small bowel, resection of the infarcted segment of the terminal ileum, and side-side anastomosis using Endo GIA were performed (Figure 1).The enterotomy was closed in two layers using vicryl 2/0 stitch, and the abdomen was drained.The patient had an uneventful recovery, and follow up at 2 and 8 months identified no postoperative complications.

Discussion
Urgent laparoscopy may be the preferred method over laparotomy to manage acute bowel obstruction with signs of strangulation in a virgin abdomen. 6A trial of conservative treatment is still a valid option when also considering the clinical picture and computed tomography (CT) findings. 7][10] Most of these are managed by surgery after variable periods of conservative treatment.
The most common mode of presentation for BLH consists of abdominal pain, particularly "colicky abdominal pain", 11 and nausea and/or vomiting.Listing the full variety of presentations would be extensive, as throughout the literature symptoms such as distended abdomen, constipation, diarrhea, and headaches have all been mentioned.Blood tests and ultrasounds were initial tests in a pregnancy case. 12Over time, X-rays appear to have been replaced by CT scans for cases of BL herniation.Laparoscopy has also become a more common method of diagnosing BLH when a surgical approach is needed. 13n most early cases, diagnosis and surgical management decisions were made at the same time; in later years BLH were more commonly diagnosed through laparoscopy.This was further confirmed in a 2007 study, which highlighted that laparoscopy has shown positive results thus far and stressed that laparoscopy should be the first-line surgical management for patients. 14The defects in most cases were closed to prevent reoccurrences, and the herniating material was often resected with uneventful recoveries.Laparoscopic treatment has been argued in the majority of modern literature to provide the patient with greater postoperative comfort and shorter periods of hospitalization when compared to open surgery. 4Laparoscopy also allows for definitive diagnosis and immediate treatment of internal hernias. 15his case has highlighted the importance of early diagnosis and successful management of BL internal hernia using the minimal access approach.Gynecologists and surgeons should have a high index of suspicion for early diagnosis and management of BLH to avoid drastic morbidity.

Conclusion
Laparoscopic management of small bowel obstruction due to broad ligament internal hernia is a safe and effective option.The literature shows that surgical management is the only safe option in these patients.