24 January 2025: Review Articles
Characteristics and Associated Risk Factors of Broad Ligament Hernia: A Systematic Review
Kelsey Dowers

DOI: 10.12659/MSM.946710
Med Sci Monit 2025; 31:e946710
Abstract
ABSTRACT: The broad ligament, a double-layered peritoneum attaching the lateral uterus to the pelvic sidewall, plays a vital role in pelvic anatomy. Small bowel herniation through a defect in the broad ligament, known as broad ligament herniation, involving protrusion of viscera through defects in this ligament, is rare but can lead to severe complications. This systematic review aims to evaluate the presentation, diagnosis, management, and factors associated with broad ligament herniation. Following PRISMA guidelines, a systematic search was conducted in PubMed and Cumulative Index to Nursing and Allied Health Literature databases using the terms “broad ligament AND hernia” and “broad ligament AND herniation”. Case reports and series with detailed anatomical descriptions were included. Articles not in English or without full-text access were excluded. Extracted data included patient demographics, history of abdominal surgeries, herniated organs, and classification. Results were synthesized to identify patterns and risk factors. A total of 71 articles met the inclusion criteria, with patients predominantly aged 30 to 49 years. A history of abdominal surgery and multiparity were noted to be key risk factors. The small bowel was the most herniated organ (90% of cases). The fenestra type defect accounted for 88.9% of cases, and CT imaging emerged as the preferred diagnostic modality. Detailed surgical and medical histories are crucial in diagnosing broad ligament herniation. Future research should focus on pathogenesis and standardized classification systems to improve management strategies.
Keywords: Broad Ligament, Uterus, Hernia, Hernia, Abdominal
Introduction
The broad ligament, also known as ligamentum latum uteri, is a double fold of peritoneum that that extends from the lateral edges of the uterus to the pelvic sidewalls. It plays a vital role in supporting the uterus and contains critical vasculature for both the uterus and adnexa. It functions alongside the cardinal ligaments, uterosacral ligaments, and pubocervical ligaments to maintain the position of the uterus in the pelvic cavity [1,2].
During embryological development, the paramesonephric (Müllerian) ducts fuse to become the female pelvic organs, which are subsequently enveloped by 2 layers of the peritoneum referred to as the broad ligament [1]. The broad ligament is anatomically divided into 3 subdivisions: the mesometrium: the largest portion, attaching the uterus to the sidewall and spreading laterally to cover the external iliac vessels; mesosalpinx: encloses the uterine (fallopian) tubes; and mesovarium: the posterior fold connecting the anterior surface of the ovary, which contains the ovarian vasculature within the suspensory ligament [3]. Defects of the broad ligament can result in the herniation of adjacent organs and are due to either congenital or acquired causes. Congenital causes include the rupture of cystic remnants of the paramesonephric duct, whereas acquired causes include trauma from surgery or pregnancy, endometriosis, or inflammation [4]. For example, postoperative adhesions from gynecological surgeries, such as caesarean sections, can predispose patients to broad ligament herniation (BLH) by weakening the peritoneal folds [5]. Studies have shown documented instances of BLH occurring after surgical intervention, suggesting that the mechanical stress of surgery can exacerbate or create peritoneal defects [6].
Internal hernias occur when there is a protrusion of abdominal organs into the pelvic or abdominal cavity through an orifice in the peritoneum or mesentery [7]. These conditions are relatively rare, accounting for approximately 5% of abdominal hernias, with BLH representing approximately 6% of internal hernias [6,7]. Etiologies include adhesions following surgery, inflammatory bowel disease, and malignancy [6]. As bariatric surgeries, such as Roux-en-Y gastric bypass, become more prevalent, the incidence of internal hernias is rising if not managed promptly [8,9].
Diagnosing BLH is challenging due to its rarity and nonspecific clinical presentation including abdominal pain, nausea, and vomiting [10]. Consequently, many cases are diagnosed intraoperatively, often after complications arise [2]. Delayed diagnosis can lead to increased morbidity, emphasizing the need for greater awareness of this condition among clinicians [4]. Therefore, this systematic review aims to evaluate the presentation, diagnosis, management, and factors associated with BLH. Specifically, it seeks to identify relevant patient factors, classify hernias and analyze surgical histories and the organs involved to provide a comprehensive understanding of this rare clinical presentation.
Material and Methods
SEARCH STRATEGY:
This systematic review was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). An initial search of the literature was performed using the PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. The search terms included: “broad ligament AND hernia” and “broad ligament AND herniation” To ensure a comprehensive search, the inclusion criteria were not restricted by publication year, patient age, ethnicity, or country. This broad approach aimed to capture all relevant publications available in the databases.
CRITERIA FOR STUDY SELECTION:
The inclusion and exclusion criteria for this review were predefined to ensure the relevance and quality of selected articles. The inclusion criteria were as follows: (1) case reports, (2) case series, and/or (3) articles that provided detailed anatomical description of the broad ligament herniation either through imaging findings or surgical findings. The exclusion criteria were as follows: (1) animal studies, (2) studies involving broad ligament unrelated to ligamentum latum uteri, and/or (3) articles without full-text availability in English.
ANALYSIS:
Descriptive analysis was performed to summarize the findings from the included studies. The presentation, diagnosis, classification, and management strategies of BLH were analyzed to identify common trends and variations.
Results
STUDY IDENTIFICATION:
A total of 164 articles were identified from the initial search: 153 articles from PubMed and 11 articles from CINAHL. After deduplication and removal of articles based on irrelevant titles or abstracts, 45 articles were excluded. Screening for full-text retrieval in English led to the exclusion of an additional 18 articles. At the final screening stage, 41 articles were excluded because they did not provide detailed anatomical descriptions of broad ligament hernia pathology, either through imaging or surgical findings. Ultimately, 71 articles met the inclusion criteria and were included in this systematic review. A flowchart illustrating the screening and selection process is presented in Figure 1.
CHARACTERISTICS OF INCLUDED REPORTS:
A total of 71 articles were included, with 6 of these reporting multiple case studies, resulting in 67 individual cases of BLH for analysis. Three main themes emerged from the review of the articles: abdominal surgical history, type of herniated organ, and classification systems.
ABDOMINAL SURGICAL HISTORY:
Among the 67 cases analyzed, 25 (37.3%) had a history of abdominal surgery, 33 (49.3%) did not, and 9 (13.4%) did not mention any surgical history. Of the cases with an abdominal surgical history, 14 (20.9%) also reported confirmed parity history. Across all cases, parity history was confirmed in 37 cases (55.2%), not present in 14 cases (20.9%), and unknown in 16 cases (23.9%).
The age distribution of patients showed variability, ranging from under 18 to over 70 years old. The most common age group was 30–39 years, accounting for 22 cases (32.8%). The distribution was as follows: below 18 years: 1 case (1.5%); 20–29 years: 4 cases (6.0%); 30–39 years: 22 cases (32.8%); 40–49 years: 22 cases (32.8%); 50–59 years: 10 cases (14.9%); 60–69 years: 2 cases (3.0%); 70 years and older: 5 cases (7.5%); and unspecified age: 1 case (1.6%).
Special consideration is warranted for older adults, particularly postmenopausal women with a history of gynecological surgeries. These individuals are at higher risk of BLH, likely due to reduced tissue elasticity and weakening of pelvic structures following procedures such as hysterectomy. This emphasizes the importance of vigilant postoperative monitoring for early detection and management of complications.
TYPE OF HERNIATED ORGAN:
In 66 cases, the herniated organ was identified. The most commonly affected organ was the intestinal tract, reported in 47 cases (71.2%), followed by the bladder in 16 cases (24.2%), and the ovaries in 3 cases (4.5%).
CLASSIFICATION OF BLH:
The fenestra type of BLH was the most frequently reported, with 57 cases (86.4%). Other classifications included 1 case (1.5%) of the pouch type and 3 cases (4.5%) of the hernia sac type.
Additionally, 30 cases were classified using the Cilley classification system: type 1: 20 cases (66.7%); type 2: 8 cases (26.7%); and type 3: 2 cases (6.7%). The classification systems of Cilley and Hunt are depicted in Figures 2 and 3, respectively. Table 1 provides a summary of patient characteristics and hernia classifications, illustrating commonalities and diversity in the presentation of BLH.
ASSOCIATIONS WITH ABDOMINAL SURGERY:
The findings from this review support previous studies suggesting a link between multiple pelvic surgeries and BLH. Repeated surgical interventions can weaken or create defects in the broad ligament, increasing the risk of hernia development. These findings highlight the need for clinicians to maintain a high index of suspicion for BLH in patients presenting with nonspecific abdominal symptoms, particularly those with a history of multiple abdominal surgeries.
Discussion
IMPLICATIONS FOR CLINICAL PRACTICE:
The findings from this review have significant implications for clinical practice. The association between prior abdominal surgeries and BLH highlights the importance of obtaining a detailed surgical history when evaluating patients with nonspecific abdominal symptoms. Additionally, healthcare providers should consider BLH as a differential diagnosis, particularly in older women or those with a history of multiple pelvic surgeries, as these individuals can have an elevated risk of hernia development.
Furthermore, the variability in clinical presentations, ranging from asymptomatic cases to acute bowel obstruction, stresses the need for vigilance and thorough diagnostic imaging. Surgical teams should adopt standardized classification systems to describe hernia cases comprehensively, facilitating better communication and aiding in the development of evidence-based management strategies.
LIMITATIONS:
Many articles lacked detailed anatomical descriptions of the hernia, resulting in their exclusion from the analysis. Additionally, some studies focused primarily on treatment procedures rather than the initial anatomical findings, limiting the scope of data available for review.
Another limitation was the incomplete reporting of patient parity, with no detailed information on the number or mode of deliveries, such as vaginal versus cesarean deliveries, which could have provided a more nuanced understanding of acquired hernias. The time interval between prior surgical procedures and the development of BLH was inconsistently reported, with significant gaps in the literature regarding the pathophysiological mechanisms involved.
Additionally, the lack of information on geographic location, ethnicity, and genetic predispositions prevented an analysis of potential demographic or hereditary factors associated with BLH. The paucity of reports on bilateral or recurrent BLH also limited comparisons with established baselines.
Finally, limitations regarding the methods of this review include the possibility that rare cases of BLH may not always be reported in the available literature, and the exclusion of non-English articles, which could have led to the omission of relevant studies. Future research should aim to address these gaps by standardizing reporting and classification of BLH, to improve our understanding of its pathogenesis and optimal management strategies.
Conclusions
BLH is a rare and potentially serious condition that occurs from a weakening in one or both peritoneal folds, leading to herniation of abdominal or pelvic organs. This systematic review highlights the importance of considering the internal hernias, particularly BLH, in female patients presenting with nonspecific abdominal symptoms or intestinal obstruction. While the small bowel is the most commonly herniated organ, other organs can also be involved, potentially altering the clinical presentation. This emphasizes the need for detailed patient history and accurate classification, such as the standardized classification systems proposed by Hunt and Cilley, to enhance the understanding of this rare pathology and improve diagnostic and management strategies. In conclusion, although BLH is rare, prompt recognition and intervention can significantly reduce morbidity. Further studies using standardized classifications and detailed reporting are necessary to enhance our understanding of the prevalence, pathogenesis, and optimal management approaches of BLH.
Figures

![Illustration of Cilley’s classification of broad ligament herniation. The classification is divided into 3 distinct types based on the location and extent of the herniation: Type 1: A defect occurs in the broad ligament’s mesosalpinx, through which bowel loops may herniate. Type 2: A defect is found in the entire broad ligament but spares the uterine attachment, allowing organs such as the bowel to pass through. Type 3: A complete trans-ligamentous defect where the herniation occurs through the broad ligament’s entire thickness, often involving large segments of bowel.In the figure, arrows point to the sites of herniation, with numbers identifying each type of defect: Type 1 defect, type 2 defect, and type 3 defect.Each type is visually represented by shaded areas to distinguish between different defect locations within the broad ligament. The anatomical landmarks, including the uterus and adjacent structures, are indicated to clarify the relation between the defect and surrounding tissues.BL – broad ligament; UT – uterus.The image was prepared using professional image-editing software. This image was created by Janine Murta, BA, MSc, a faculty medical illustrator at St. George’s University School of Medicine. No AI or generative features were used in the process of creation. This illustration was developed from scratch using Adobe Illustrator and Photoshop version 25.12 (industry standard software for art and asset creation). The image creation process involved sketching various angles of the anatomy and selecting the best view to encompass all the types of broad ligament herniation. Once the best angle was chosen, further refinement, color, and details were rendered. The final image demonstrates the culmination of this refinement and rendering. [© 2024, Janine Murta, BA, MSc].](https://jours.isi-science.com/imageXml.php?i=medscimonit-31-e946710-g002.jpg&idArt=946710&w=1000)
![Illustration of Hunt’s classification of broad ligament herniation. The classification is divided into 3 distinct types based on the location and extent of the herniation: Fenestra type: A defect occurs in the broad ligament’s mesosalpinx, through which bowel loops can herniate. Pouch type: A defect is found in the entire broad ligament but spares the uterine attachment, allowing organs such as the bowel to pass through. Hernia sac type: A complete trans-ligamentous defect where the herniation occurs through the broad ligament’s entire thickness, often involving large segments of bowel.The image was prepared using professional image-editing software. This image was created by Janine Murta, BA, MSc, a faculty medical illustrator at St. George’s University School of Medicine. No AI or generative features were used in the process of creation. This illustration was developed from scratch using Adobe Illustrator and Photoshop version 25.12 (industry standard software for art and asset creation). [© 2024, Janine Murta, BA, MSc].](https://jours.isi-science.com/imageXml.php?i=medscimonit-31-e946710-g003.jpg&idArt=946710&w=1000)
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