Strangulating Closed-Loop Ileal Obstruction Caused by Broad Ligament Hernia with Ileal Perforation: A Case Report

Abstract

A broad ligament (broad band) hernia is a rare internal hernia caused by small bowel herniation through a defect of the broad ligament, often presenting as intestinal obstruction. Delayed diagnosis may progress to strangulation and generalized peritonitis. We report a case of strangulating closed-loop ileal obstruction caused by broad ligament hernia complicated by ileal perforation. A 51-year-old woman was initially treated conservatively for 10 days at Jepara District Hospital for colicky abdominal pain suspected to be adhesive small bowel obstruction, despite no prior abdominal surgery. Nasogastric decompression, intravenous fluids, and nutritional support resulted in temporary improvement, and she was discharged. Symptoms recurred one day later, and plain abdominal radiography suggested small bowel obstruction; conservative treatment was continued. The next day she developed diffuse abdominal pain worsening with movement. Repeat radiography revealed free air under the diaphragm, and she was referred to St. Elizabeth Hospital, Semarang, with generalized peritonitis due to intestinal perforation. Emergency laparotomy found gas, fibrin, pus, and fecal contamination, with a distended ileal segment trapped in the pelvic cavity on the left side of the uterus. Two constriction rings were identified, with a bowel perforation at one site. A ~2 cm defect in the left broad ligament was confirmed. The constriction ring was opened up, the bowel was freed, the defect was sewn up, and a loop ileostomy was done. The patient recovered well and was discharged on postoperative day seven. Internal hernia should be considered in small bowel obstruction without previous surgery, and early abdominal CT is recommended to improve diagnostic accuracy and prevent life-threatening complications.