the surgical indication is difficult to establish in some cases ( more than 40% ) . acute abdominal pain in women may be a manifestation of a disorder of various organs . in addition to surgical , urological , orthopedic , neurological , and psychogenic problems , gynecological causes play a major role . incarcerated herniation of the bowel , occurring through a defect in the broad ligament , is extremely rare . we herein report the 2 cases of women with intestinal obstruction , neither of whom had a previous history of any surgical pelvic treatment . the laparoscopic approach revealed in both cases an incarceration of the small bowel herniated through a defect in the broad ligament . without the antecedent of uterine surgery , delivery trauma , and pelvic diseases , congenital abnormalities are considered the causes of these defects although the real mechanism is unknown . this cause should therefore be considered in the differential diagnosis of female patients presenting with an intestinal obstruction who have not had a prior laparotomy . a 38-year - old gravida 1 , para 1 , woman was admitted to our hospital with a chief complaint of lower abdominal colicky pain and vomiting of 1 day 's duration . her relevant past medical history included a laparoscopic appendectomy performed 7 years previously and a diagnosis , in the same setting , of endometriosis , since then successfully treated with medical therapy . laboratory findings showed slight leucocytosis , and a plain abdominal radiograph showed some loops of dilated small bowel with air fluid levels . ultrasonography confirmed the small bowel obstruction and disclosed the presence of fluid in the pelvis . with the diagnosis of intestinal obstruction of unknown origin because abdominal distension was moderate , a laparoscopic approach was performed with 3 trocars , instruments , and optics 5-mm in diameter . a 30-cm long ileal loop was found to have herniated through a defect in the right broad ligament . a 23-cm defect was noted , and it was closed by using a purse - string 2/0 monofilament absorbable suture . the postoperative course was uneventful , with bowel movement and hospital discharge on the first and fourth postoperative days , respectively . a 55-year - old gravida 2 , para 2 woman was admitted to our department with symptoms of colicky pain and nausea but no vomiting for the previous 2 days . most notable , she had no history of prior abdominal or pelvic surgery or pelvic inflammatory disease . on examination , as with the previous case , a plain abdominal radiograph showed some loops of dilated small bowel with no air fluid levels . ultrasonography confirmed the small bowel obstruction and disclosed the presence of fluid in the pelvis . due to a diagnosis of intestinal obstruction of unknown origin , the patient was taken into the operating room and a laparoscopic approach was used in the same manner as the case described above . a 20-cm long ileal loop was found to have herniated through a fenestration of the left broad ligament . as above , the small bowel , once reduced , appeared vital , and a defect of 13 cm was seen and closed by using a purse - string monofilament absorbable 2/0 suture . the postoperative course was uneventful , with bowel movement and hospital discharge on the first and third postoperative days , respectively . surgeons treating a patient with lower abdominal pain of uncertain origin are caught between the extremes of conservative and operative treatment . after clinical examination and ultrasonography , exploratory laparoscopy has been shown by several studies to solve this therapeutic dilemma . a corollary to the application of diagnostic laparoscopy is the potential for therapeutic manipulation during the same setting . internal hernias represent only 0.4% to 4.1% of all small bowel incarcerations , and of these , the hernias through a defect of the broad ligament represent only 4% to 7% . regarding their  cause ,  they are thought to be either congenital or acquired . the congenital ones are a consequence of a spontaneous rupture of congenital cystic structures within the broad ligament reminiscent of the mesonephric or mllerian ducts . this hypothesis could account for those patients who are nulliparous or have never undergone pelvic surgery . an acquired defect may result from either operative trauma , pregnancy and birth trauma , or prior pelvic inflammatory disease . they have therefore been frequently reported in multiparous patients , patients who have undergone a surgical pelvic procedure , and patients with a history of salpingitis or endometriosis . one of our patients had only a history of multiple pregnancies and deliveries , and the other patient with endometriosis had an appendectomy . a classification of broad ligament defects has been proposed based on their anatomical position : type 1 defect , which occurs throughout the entire broad ligament ; type 2 , which occurs throughout the mesosalpinx and the mesovarium ; and type 3 , which occurs throughout the meso - ligamentum teres . plain film radiography because of its low sensitivity and specificity helps little in the diagnosis of most causes of abdominal pain due to gynecological disorders . other radiological investigations , such as either ultrasonography or ct scan , or both used together , are expensive and not possible to perform in all hospital situations , 24 hours a day . diagnostic laparoscopy , with an accuracy of more than 90% has been demonstrated to be superior to other diagnostic tools and may lead to the correction of an erroneous preoperative diagnosis in up to 40% of patients , or it may be used to exclude other pathologies . a corollary to the application of diagnostic laparoscopy is the potential for therapeutic manipulation during the same setting , which has been reported in the literature to be more than 80% . the goal of surgical treatment includes reduction of the intestinal loop ( its resection , if needed ) , and direct closure of the opening to avoid any recurrence . only one report exists in literature , to the best of our knowledge , of a pathology totally diagnosed and treated by using laparos - copy . for more than 10 years , we have been using laparoscopy routinely in both scheduled and emergency situations , if no absolute contraindication to the technique is present . in both cases reported herein , the laparoscopic approach was possible to perform due to the mild intestinal gas distension . intestinal resection was not necessary , and we closed the opening of the broad ligament with a purse - string absorbable suture . early diagnosis and , if possible , therapeutic laparoscopy is cost - effective in many scenarios dealing with managing nonspecific acute ( low ) abdominal pain , especially in women of reproductive age . thus , the following is perfectly applicable to the 2 cases we have report herein : both were rare gynecological pathologies causing small bowel obstruction that were diagnosed and treated in the same setting with good results and perceptions of the patients . we do think that laparoscopy is not an alternative to physical examination and conventional noninvasive diagnostic methods in any acute abdominal situation . however , it must be considered an effective option in patients in whom these methods fail , especially as surgeons become more experienced and skilled .
two cases of internal herniation through a defect in the broad ligament of the uterus are described . 
 both were successfully treated laparoscopically . 
 this rare condition should be borne in mind when a middle - aged woman presents with colicky lower abdominal pain . 
 the cause is unknown , but both congenital and acquired origins have been proposed . as far as emergency situations are concerned , 
 laparoscopy has proven to be both a diagnostic and a therapeutic tool .