A 47-year-old woman consulted the emergency department for an 8-hour history of continuous and diffuse abdominal pain, together with vomiting, first of food and then bilious vomiting. The patient's only personal history was two caesarean sections. In the ED she presented with a blood pressure of 122/85 mmHg, a heart rate of 91 beats per minute and an axillary temperature of 35.9 oC. Abdominal examination reveals an infraumbilical mid-laparotomy scar, the presence of diminished sounds, and diffuse pain on palpation without clear signs of peritoneal irritation. There are no inguinal or crural hernias.
Blood tests showed only a glycaemia of 122 mg/dL, a leukocytosis of 15,240 uL, together with neutrophilia of 93%, with the rest of the parameters being normal. The simple abdominal X-ray was compatible with small bowel subocclusion and cholelithiasis. The emergency CT scan revealed the presence of dilated small bowel loops and suggested the possibility of intestinal torsion.

The findings in the complementary examinations, together with the clinical worsening of the patient during the period of observation and study, increasing vomiting and abdominal pain, as well as the appearance of signs of peritoneal irritation in the lower hemiabdomen, led to the proposal of an exploratory laparoscopy. The suspected diagnosis at that time was intestinal occlusion by flanges, and the time elapsed since admission to the emergency department was 16 hours.
Under general anaesthesia, exploratory laparoscopy was performed, identifying a strangulated and necrotic small bowel loop in the patient's pelvis. This loop occupies the right side of figure 3 (purple/black), which is an intraoperative photograph taken directly from the laparoscopic camera monitor. The left side of this image corresponds to the pre-herniary ileum (normal pink), between both ileum zones is the right fallopian tube which is attached to the anterior abdominal wall and below it is the broad ligament (not visible in the image) and which would have the orifice through which the herniation occurs, in figure 4 the author represents a schematic drawing to better understand the anatomy of the intraoperative findings. The large dilatation of the small bowel loops greatly reduces the working space needed to manipulate the surgical instruments by laparoscopy. This fact, together with the risk of perforation when manipulating the necrotic loop, as well as the impossibility of identifying the anatomical structures with certainty, make it necessary to convert to open surgery. The reconversion was performed by means of an iterative infra-umbilical laparotomy and it was found that the cause of the obstruction and strangulation of the ileum was an internal hernia through the right leaflet of the broad ligament of the uterus. The hernia was reduced, 25 cm of necrotic ileum was resected and reconstructed with a manual end-to-end anastomosis. The hernial orifice is closed with a continuous 0/0 silk suture. The postoperative period passed normally and the patient was discharged with good clinical condition 11 days after admission. Postoperative control at one month is correct.

