Overview
Background
The broad ligament is a peritoneal fold that attaches the uterus, fallopian tubes, and ovaries to the pelvis. Disorders of the broad ligament are rare and review of medical literature reveals mostly case reports. In this article, the most reported disorders are discussed.
Embryology
The broad ligaments are formed after the fusion of both müllerian ducts. This fusion brings together 2 peritoneal folds that become the broad ligament on each side of the fused müllerian ducts. The müllerian ducts eventually canalize and become the uterus, the fallopian tubes, and the cervix.
Anatomy and physiology
The broad ligament is a double-layered sheet of mesothelial cells. It extends from the sides of the uterus medially to the pelvic sidewalls laterally and the pelvic floor inferiorly. Superiorly, it engulfs sequentially from anterior to posterior the round ligaments, fallopian tubes, and utero-ovarian ligaments. Medially, it encloses the uterus, and laterally, it encloses the ovarian vessels forming the infundibulopelvic ligament, attaching the ovaries to the lateral pelvic sidewall. The 2 layers of the broad ligaments are continuous with each other at a free edge that surrounds the fallopian tubes.
Between the 2 layers of the broad ligament is extraperitoneal tissue referred to as the parametrium and consists of connective tissue, smooth muscles, nerves, and blood vessels. The mesovarium is a short peritoneal fold that attaches the anterior border of the ovary to the posterior leaf of the broad ligament. The mesosalpinx is the part of the broad ligament that lies between the utero-ovarian ligament, the ovary, and the fallopian tube.
Together with the uterus, the broad ligament forms a septum across the female pelvis, dividing that cavity into 2 compartments—in the anterior part is the bladder and in the posterior part is the rectum. The broad ligament is believed to hold the uterus in its normal position within the pelvis and maintains the relationship of the fallopian tubes to the ovaries and the uterus, a role that might be important in reproduction. However, the broad ligament plays a minimal role, if any, in pelvic support. The principal support of the uterus is the pelvic floor.
Disorders of the Broad Ligament
Anatomic defects and internal herniation
Anatomic defects of the broad ligament can be either congenital (as a result of a developmental defect) or acquired. Several factors have been attributed to causing these defects, including trauma during pregnancy or delivery, pelvic inflammatory disease, endometriosis, and surgical damage. Congenital cystic structures have been described within the broad ligament as remnants of the mesonephric or müllerian ducts. When these cysts rupture, they have been hypothesized to leave behind a defect in the broad ligament. Spontaneous rupture of these cysts could account for defects in patients who are nulliparous, have never undergone a pelvic surgical procedure, or have never had pelvic inflammatory disease. Operative, birth, or pregnancy traumas may also induce such a defect in the broad ligament by rupturing the cystic embryologic remnants. [1]
Although most commonly unilateral, the defect can occur bilaterally. Hunt classified broad ligament defects into 2 types [2] :
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The fenestra type: The defect involves both the anterior leaf and the posterior leaf of the broad ligament, creating an open window anteriorly to posteriorly.
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The pouch type: The defect involves only 1 layer, either the anterior leaf or the posterior leaf of the broad ligament.
Cilley et al proposed another classification depending on the anatomic location of the defect. [3]
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Type I defects are by far the most frequent and occur through the whole broad ligament.
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Type II defects occur through the mesosalpinx and the mesovarium.
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Type III defects occur through the mesoligamentum teres.
Fafet et al later added a fourth type, in which the defect involves only the mesosalpinx. [4]
Internal herniation of the small bowel is a rare cause of intestinal obstruction, [5] accounting for 1-4% of all cases. Internal herniation through a defect in the broad ligament is even rarer, representing 5-7% of all internal herniations. [6, 7, 8, 9, 10, 11, 12, 13] Usually the ileum is involved, although a rare case of herniation of the colon has been reported. [14] Most herniations occur with the fenestra-type defect, with only 3 of 57 cases reported in Japan being attributed to the pouch-type defect. [15] Also, the length of the herniated loop (up to 100 cm reported) is greater through a fenestra-type defect than through a pouch-type defect. Herniation can occur either from anterior to posterior or in the opposite direction, and the herniated loop can displace the uterus to the contralateral side. [16]
Typically, the patient presents with acute abdomen, nausea, and vomiting. Early diagnosis is crucial to provide prompt surgical intervention by releasing the strangulated loop and avoiding intestinal ischemia, necrosis, and perforation. KUB shows dilated small bowel loops with air-fluid levels. CT scan of the abdomen and pelvis is diagnostic, and the finding of a herniated loop with its ends close to the uterus is suggestive of an internal herniation through a defect in the broad ligament. [17]
Surgical treatment of the incarcerated bowel through a broad ligament defect is an emergency and includes reduction of the intestinal loop, intestinal resection, if needed, and secondary prevention of the recurrence by either broad ligament division and subsequent repair or direct closure of the defect. Guillem et al reported one case where the herniated small bowel was reduced laparoscopically and the defect was closed using a laparoscopic absorbable clip. [1] Hashimoto et al described the case of a recurrent hernia in the broad ligament that was repaired with two-layer closure with nonabsorbable suture in order to prevent recurrence. [16]
A case of isolated tubal torsion herniating through the broad ligament has been described. [18]
Hassadia et al reported the first case of bilateral adnexal herniation through the broad ligaments in a 41-year-old woman who presented with pelvic pain and heavy periods. During laparoscopy, both ovaries were found to have herniated through the broad ligament into the anterior compartment. [19] Others have reported similar cases involving a single adnexa. [20, 21, 22] In the case presented by Hassadia et al, the herniation occurred through a previously noted broad ligament defect that was not repaired; their case demonstrates the importance of repairing such a defect when incidentally noted in order to prevent future herniation. [19]
Broad ligament laceration: Allen-Masters syndrome
Allen-Masters syndrome, also known as the universal joint cervix syndrome, was first described in 1955 and is considered a rare cause of chronic pelvic pain in women. [23] However, only limited documentation exists in medical literature regarding this condition and only a small number of physicians, mainly in France, support it. These physicians claim that the main underlying pathology is a laceration of the fascial layers in the broad ligament, resulting in a universal joint type of mobility of the cervix, which may be moved in any direction with minimal, if any, movement of the uterus. The condition usually results from surgical or traumatic lacerations of the broad ligament during delivery or, less frequently, from induced abortion, particularly as a result of excessive vaginal packing. Patients usually report persistent pelvic pain, dyspareunia, menstrual disturbances, and back pain. [24]
Priou reported this syndrome in 3.8% of cases in his series of 184 laparoscopic examinations of women with chronic pelvic pain. [25] Clinical findings consist of uterine retroversion with hypermobile cervix following elongation or disinsertion of the uterosacral ligaments. Anatomic findings consist of a tear in the posterior serosa and subperitoneal fascia of the broad ligament.
German investigators suggested that classic risk factors for Allen-Masters syndrome (eg, body mass index, spontaneous births) and/or mechanical damage of the lesser pelvis may not be solely responsible for this condition in patients with and without endometriosis. [26] In their retrospective cohort study (2009-2011), the classic risk factors were present in only 8 of 26 patients (30.77%) with Allen-Masters syndrome and endometriosis who underwent laparoscopy for chronic pelvic pain.
von Theobald et al suggested that douglasectomy is the only definitive procedure to restore normal anatomy of the pelvic floor in case of painful uterine retroversion occurring in the setting of Allen-Masters syndrome. In their series of 41 patients treated by laparoscopic douglasectomy, they claimed that 75% of the patients had total pain relief, 12% had partial relief, and 12% had no relief. [27] The procedure was described as follows:
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Dissection of the peritoneum over the pouch of Douglas: The incision of the peritoneum is made just above the uterosacral ligaments extending anteriorly from the lower edge of the uterine corpus to the anterior wall of the rectum posteriorly.
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Ligamentopexy of the uterosacral ligaments is performed using 3-4 separate absorbable stitches or stapling.
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Reapproximation of the free edges of the peritoneum is performed.
In their series, one case was complicated by intraoperative bleeding necessitating conversion to laparotomy, one by retroperitoneal hematoma, and another by postoperative endometritis. They observed the patients for an average of 2.9 years and noted no recurrence of pelvic pain.
Broad ligament hematoma
Broad ligament hematoma results from a tear in the upper vagina, cervix, or uterus that extends into uterine or vaginal arteries, most commonly following operative delivery, trauma, or surgery, but it may also occur following spontaneous vaginal delivery. Hematomas caused by tears during dilatation during D&C or D&E procedures are probably the most common causes of broad ligament hematomas. These can be dangerous as they may be silent and not cause obvious vaginal bleeding. The risk of hematoma formation may be increased with congenital coagulopathy. Malhotra et al reported a case of fetal death caused by bilateral broad ligament hematomas in the absence of any injury to the uterus, placenta, or the fetus following pelvic fractures sustained in a pregnant woman during a motor vehicle accident. [28]
Duckett et al reported a case of spontaneous broad ligament hematoma that occurred in a nonpregnant woman after mowing the lawn. The patient had a large fibroid uterus and the authors presumed that a venous vascular injury occurred leading to the formation of the hematoma. [29]
Most patients report back pain, fullness or pressure in the rectoanal area, or an urge to push, or they complain of dizziness and eventually may become hypotensive and anemic. This is a potentially life-threatening condition. Since vaginal bleeding may not be present, diagnosis may be delayed. A rectovaginal exam should be performed to rule out the presence of clots in the vagina or the possibility of an expanding vaginal hematoma.
Jain et al suggested that a pelvic MRI should be used to evaluate patients with persistent postpartum localized pelvic pain, fullness or discomfort, or a sudden drop in hematocrit level with no apparent source of bleeding. They reported 7 cases of patients having postpartum hemorrhage nonapparent to the clinical examination; in these cases, hematoma was successfully diagnosed by MRI. [30]
Broad ligament hematoma may be treated either conservatively with blood transfusion, fluid resuscitation, and observation or with surgical exploration and evacuation. Muthulakshmi et al reported a case of broad ligament hematoma following spontaneous vaginal delivery that was successfully treated by uterine artery embolization. [31]
Parametritis
Parametritis is infection of the parametrial tissue, which usually results from an ascending infection, and is classified under pelvic inflammatory disease. (See Pelvic Inflammatory Disease and Fallopian Tube Disorders.)
Broad ligament ectopic pregnancy
Broad ligament ectopic pregnancy, also known as intraligamentary pregnancy, is a rare form of ectopic pregnancy first described in 1816 by Loschge. [32] It is a retroperitoneal pregnancy that develops within the leaves of the broad ligament. [33] Champion et al defined the required anatomic relationships to diagnose a broad ligament ectopic pregnancy: (1) the uterus located medially to the ectopic pregnancy, (2) the pelvic side walls located laterally, (3) the pelvic floor located inferiorly, and (4) the fallopian tube located superiorly. In their published series of 62 cases, Champion et al reported an incidence of broad ligament ectopic pregnancy in 1 of 183,900 pregnancies. [34] Others have reported an incidence of 1 in 75 to 1 in 613 ectopic pregnancies. [35, 36] The diagnosis is seldom established before surgery, although Phupong et al reported a case that was diagnosed preoperatively. [37]
See Ectopic Pregnancy and Fallopian Tube Disorders.
Endometrioma and endometriosis
The posterior broad ligament can frequently be affected by endometriosis, especially in the presence of endometrioma. Mereu et al found that among 124 excised endometriomas, 122 (98.4%) had dense adhesions involving the ipsilateral posterior broad ligament. [38] Deep endometriosis affected 86 (70.5%) patients and superficial infiltration involved 36 (29.5%) patients. Endometriosis was rarely (1.6%) confined exclusively to the ovary. They concluded that these findings support the notion that endometrioma seems to be a indicator for more extensive disease.
Broad Ligament Tumors
Tumors of the broad ligaments are rare. The most common solid tumor of the broad ligament is a leiomyoma. This tumor can arise from any tissue that contains smooth muscle cells, but most commonly from the uterus. Broad ligament leiomyoma can originate from the uterus and invade the broad ligament or it can originate from the broad ligament itself. These benign tumors are usually asymptomatic. However, if the leiomyoma reaches significant size, it can distort the anatomy of the pelvis, pushing the uterus to the contralateral side, and it can potentially compress the ureter, which leads to hydronephrosis.
Primary leiomyosarcomas of the broad ligament are extremely rare with only a few cases reported in medical literature. Duhan et al reported a case of leiomyosarcoma in a 45-year-old woman 4 years after hysterectomy. [39]
Gardner et al have established the following criterion: the disease should be "completely separated from and in no way connected with either the uterus or the ovary." [40]
Leiomyosarcoma is differentiated from leiomyoma microscopically by the following:
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Five or more mitotic figures per 10 high-power field (HPF)
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Hypercellularity
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Nuclear atypia
The microscopic pattern plays a crucial role in defining overall prognosis and the need for adjuvant therapy. Initial management is the same as that of leiomyosarcoma of the uterus — total abdominal hysterectomy with bilateral salpingo-oophorectomy. Pelvic lymph node dissection is debatable. Adjuvant treatment is empirical at this time since data is lacking. It consists of chemotherapy and/or radiation. [39]
Other extremely rare primary tumors of the broad ligament that have been reported include the following:
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Steroid cell tumor outside the ovary or the adrenal gland is rare but can occur in any tissue, including the broad ligament, and cause virilization. [43]
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Papillary cystadenoma of the broad ligament can arise in patients with von Hippel-Lindau disease. These rare tumors have also been reported to occur in the epididymis [44] and peritoneum.
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An oncocytic adrenocortical adenoma arising from adrenal rest in the broad ligament of a 29-year-old Japanese patient has been reported. [45]
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An endometrioid adenocarcinoma of the broad ligament was found in a 43-year-old woman who had presented with chronic abdominal pain and intermittent urinary retention. [46]
