Intestinal obstruction associated with pouches
and fenestrae in the broad ligament
Review of the literature and report of a case
HARRY N. PAPAS, M.D.
Akron, Ohio
I N T E s T I N A L obstruction based on
broad ligament fenestrae seems to be ex-
tremely rare, even when compared with
the uncommon forms of intestinal strangu-
lations into other peritoneal fossae and
apertures. Early in 1889, Dulles 4 collected
more than 70 cases of properitoneal hernia,
and Moynihan/ in 1906, reported 81 cases
of hernia into the duodenal fossae, while
Judd, 8 in 1929, found 29 cases of strangu-
lations through holes of the mesentery.
However, there have been reported in
the literature only 44 cases of intestinal ob-
struction following protrusions and strangu-
lations of loops of bowel through defects in
the broad ligaments. In addition to these,
4 cases of defects in the broad ligament un-
associated with strangulation have been
described. Herrmann, 6 in 1925, reported one
in a nulliparous girl of 18 years in whom
bilateral pouches were discovered during
the removal of an ovarian tumor. The
second case of the 4, was that of Pemberton
and Sager, 12 who found bilateral holes at
the points where the round ligament was
brought through the broad ligament in a
Baldy-Webster operation. Masson and At-
kinson10 reported, in 1934, a case of herni-
ation of the right ovary and part of the
Fallopian tube into a fold of the right broad
From the Department of Obstetrics and
Gynecology, St. Thomas Hospital
Present address: Department of
Obstetrics and Gynecology, Akron
City Hospital.
172
'
ligament, gwmg the picture of an acute
condition of the abdomen. Our case, here
presented, is the fiftieth.
Historical
Before the twentieth century the first who
mentioned such a condition was Quain, 14
in 1861, who found it at an autopsy in a
36-year-old woman who was admitted with
a sudden, sharp pain in the lower abdomen
and who died 3 days after the onset of the
pain without being operated upon. At au-
topsy he found that the bowel was in-
carcerated in two places on the right side
of the pelvis; at one by old adhesions be-
tween the broad ligament and the mesentery
and at the other by an aperture in the
right broad ligament.
Treves, 15 in 1885, made a thorough de-
scription of "hernias" of the intestines and
peritoneum, but he did not mention broad
ligament malformations as being responsi-
ble for intestinal obstruction. Likewise,
Moynihan/ in 1906, and Watchon do not
refer to this condition.
Barnard/ in 1910, mentioned that there
was a case of hernia in a pouch in the broad
ligament in the Museum of the London
Hospital, but it was not until 1917, when
Fagge 5 reported 2 cases of intestinal ob-
struction into pouches or through fenestrae
of the broad ligament, that surgical treat-
ment was instituted. Richardson/ 6 in 1920,
reported the fir!it instance of intestinal ob-
struction following and definitely associated
with the Baldy-Webster operation.
Volume 8b
Number l
Anatomical considerations
The broad ligaments are two thin fibrous
sheets, covered on both surfaces with peri-
toneum, which extend from each side of
the uterus to the lateral pelvic wall. At the
upper end of each lateral margin of the
uterus the Fallopian tube pierces the uterine
wall. Below and in front of this point, the
round ligament of the uterus is fixed, while
behind it is the attachment of the ligament
of the ovary. On the lateral pelvic wall,
behind the attachment of the broad liga-
ment, in the angle between the elevation
produced by the diverging of the hypo-
gastric and external iliac vessels, is a slight
fossa, the ovarian fossa, in which the ovary
normally lies. The ligamentum ovarii pro-
prium extends between the ovary and the
cornu of the uterus and divides the broad
ligament into two parts: the upper, tri-
angular-the mesosalpinx-with the uterus,
Fallopian tube, and ovary, respectively, as
boundaries, and the lower, which is bordered
by the uterus medially, the ovarian liga-
ment superiorly, the pelvic wall and the
suspensory ligament of the ovary laterally.
Hunt/ in his review, stated that among 17
cases the incidence of pouches occurred 5
times and the openings 12. Where the lo-
cation of the openings was mentioned, they
were situated above the ligamentum ovarii
proprium twice and below once. The
pouches always occurred below the ovarian
ligament, near the uterus.
Etiology
The opinion of the writers regarding the
cause of the broad ligament defect differs
considerably.
Pidcock13 suggests as a possible cause of
the condition, in his case reported in March,
1924, the fact that all structures connected
with the uterus were in a relaxed condition
as a result of the pregnancy and that a
coil of intestine had, in some manner, rup-
tured the mesoligamentous fold. Dunn, 3 on
the other hand, in his review in 1926, stated
that in his case it was probable that con-
genital stomas existed because of the fact
that there were, in both broad ligaments,
Intestinal obstruction '!73
openings of about the same size which were
symmetrical and with smooth edges. No
evident previous inflammation was found.
Hunt, in his review, pointed out 3 causa-
tive factors: ( 1) congenital anomalies, (2)
internal lacerations as the result of preg-
nancy or labor, and (3) defects resulting
from previous inflammatory processes. On
the contrary, Goode and Newbern 11 be-
lieved, because of the fact that in only one
case did intestinal obstruction occur during
or shortly after the termination of preg-
nancy, that the second factor of Hunt can-
not be proved. There is no doubt that preg-
nancy must play some role, because it was
found that all except 4 patients were multip-
aras (nonpregnant). The same authors
state that, in spite of the fact the meso-
salpinx is a thin, avascular region of the
broad ligament, it is unlikely that stretch-
ing or direct pressure by loops of bowd
could produce these defects. Trauma by
repeated protrusions of loops of intestine
into congenital fenestra, however, might
produce sufficient inflammation with result-
ant fibrous tissue strong enough to strangu-
late the bowel. This causative mechanism
for intestinal obstruction requires many
years of such repeated mild trauma until
the expression of the acute picture.
The Baldy-Webster operation for utnine
snspension was, according to Baron;' the
most frequent predisposing factor. This is
due to two things: ( 1) improper closing of
the openings by stitching their edges to the
round ligament and (2) drawing the round
ligament through the broad ligament too
far lateral to the uterus or uteroovarian
ligament, thus producing tension on. and
later a tear of, the broad ligament.
Signs and symptoms-diagnosis
Pemberton and Sager made the diagnosis
of incarcerated intra-abdominal hernia in
a woman who experienced severe colicky-
like pain in the lower abdomen lO days
after a Baldy-Webster operation. However,
the only suspected intestinal obstruction
through a defect of the broad ligament in
a patient who had undergone a uterine
174 Papas
suspension 3 years previously, was made by
the Italian, Amadei. 17 In none of the other
cases reported was the diagnosis made prior
to laparotomy. The diagnosis was usually
torsion or rupture of an ovarian cyst, stran-
gulated obturator hernia, mesenteric throm-
bosis, or acute appendicitis.
Sudden, violent, and agonizing abdom-
inal pain followed by nausea and vomiting
are the most common symptoms with which
this clinical condition begins. Sometimes,
straining at stool or any other effort may
facilitate the onset of the pain, which may
be general throughout the abdomen or more
localized to a certain point, according to
the location of the lesion. The pain may
be cramplike-as in our case--or colicky-
like, constant with accentuations at short,
irregular intervals.
There are no bowel movements or pas-
sage of flatus after the onset of the symp-
toms. On palpation there is tenderness and
sometimes rigidity at the point of the le-
sion. Sometimes a mass can be palpated
in one of the lower quadrants. Rectovaginal
examination gives findings such as tender-
ness, thickening in the lateral fornix, and
occasionally a mass, but not always. In
nonobstructive herniations of bowels
through the broad ligament periodic pains
are present which are accentuated by cer-
tain movements or positiOns of the body
(pulling of the mesentery) . It is worth
while to mention here that there is ab-
sence of pain during pregnancy because of
the closure of the opening as the uterus
ascends. Previous history of a uteropexy IS
very helpful in making the diagnosis.
Treatment-prognosis
Immediate laparotomy should be per-
formed, and the incarcerated intestine
aiong with obliteration of the pouch or
fenestra must be released. Removal of the
adnexa may be preferable in an elderly
woman or if the circulation is seriously
impaired. The mortality rate and prognosis
depend on how early the abdominal ex-
ploration is instituted.
July, 1960
Am . .). Obst. & Gynec.
Case report
A 34-year-old white woman, gravida iv, para
iv, was admitted at St. Thomas Hospital on
March 18, 1955, because of a sudden, cramplike
pain of 10 hours' duration, which first began in
the epigastrium and became localized with per-
sistence in the left lower quadrant, accompanied
by nausea and vomiting.
The physical examination showed a well-
developed woman acutely ill with the following
findings: heart, normal; lungs, clear; abdomen,
soft (the patient was given a dose of morphine
sulfate) and slightly tender in the left lower
quadrant. No masses were palpated. The tem-
perature on admission was 100° F.; pulse, 100;
respirations, 20; blood pressure, 110j70. Com-
plete blood count was as follows: packed cell
volume, 38; hemoglobin, 76 per cent or 12 Gm.;
white blood count, 9,91 0.
At that time the diagnosis of rupture of a left
ovarian cyst was made. The patient had under-
gone no operations and she had had 4 full-term
normal deliveries. A flat plate of the abdomen
was taken on admission and revealed a dilated
loop of small bowel in the left pelvic region and
no urinary stones. A mass was suspected roent-
genographically in the left pelvic region, to which
a loop of bowel was thought to be adherent.
The patient was taken to the operating room,
and a laparotomy was performed. What was
thought to be an ovarian cyst on the left side
was a loop of small bowel that had entered a
small crib and formed a congenital opening in
the anterior broad ligament. There was approxi-
mately 8 inches of small bowel caught in this
opening. The bowel on first inspection, before
it was released from the congenital defect in
the broad ligament, was purplish in color. Soon
after the obstruction was released and the bowel
was pulled through the opening, the color im-
proved considerably and, with the application
of hot packs, after 30 to 45 minutes, the in-
carcerated bowel regained its normal color, and
there was no area of devitalization. An appendec-
tomy was performed. The opening in the left
broad ligament was sutured by a continuous
suture of No. 1 chromic catgut. Inspection of
the right broad ligament showed an incomplete
opening in the same region as on the left; this
was closed. The abdominal wall was closed in
the usual manner, and the patient was returned
to her room in good condition. The postopera-
tive course was uneventful, and she was dis-
charged in good condition 9 days after admission.
Volume llll
Number 1
Summary
1. An acute intestinal obstruction through
a fenestra of the broad ligament in a woman
who had never undergone previous opera-
tion is presented.
2. In spite of the rarity of this condition
its seriousness necessitates immediate inter-
vention.
3. The etiology of this condition is diffi-
cult to determine except in those cases as-
sociated with previous uteropexy.
REFERENCES
1. Barnard, H. L.: Contributions to Abdominal
Surgery, London, 1910, Edward Arnold &
Company, p. 216.
2. Baron, A.: Brit. J. Surg. 36: 91, 1948.
3. Dunn, L.: Surg. Gynec. & Obst. 42: 398,
1926.
4. Dulles, C. W.: J. A. M. A. 13: 557, 1889.
5. Fagge, C. H.: Brit. J. Surg. 5: 694, 1918.
6. Herrmann, E.: Zentralbl. Gynak. 49: 63,
1925.
7. Hunt, A. B.: Surg. Gynec. & Obst. 58: 906,
1934.
8. Judd, J. R.: Surg. Gynec. & Obst. 48: 264,
1929.
Intestinal obstruction 75
4. In an acute intestinal obstruction,
herniation of the bowel through pouches or
fenestrae of the broad ligament is om· of
the possibilities which should be borne in
mind, especially in women who have under-
gone uterine suspension.
My sincere thanks to Dr. C. Paternite, former
chief of the Obstetrics-Gynecology Department
of St. Thomas Hospital, Akron, Ohio, for per-
mission to present his case.
9. Moynihan, B. G. A.: On Retroperitoneal
Hernia, ed. 2, New York, 1906, William
Wood & Company.
10. Masson, J. C., and Atkinson, W.: Proc. Staff
Meet. Mayo Clin. 8: 293, 1933.
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12. Pemberton, J. de J., and Sager, W. W.:
, S. Clin. North America 9: 203, 1929.
13. Pidcock, B. H.: Brit. M. J. 1: 369, 1924.
14. Quain: Tr. Path. Soc. London 12: 103, 1861.
15. Treves, F.: Brit. M. J. 1: 415, 1885.
16. Richardson, E. P.: Surg. Gynec. & Obst. 31:
90, 1920.
17. Amadei, A.: Gior. ita!. chir. 2: 261. 194·6.