What Is a Broad Ligament?
The broad ligament (or round ligament) is a double-layer fold of the peritoneum that connects the uterus to the walls and pelvic floor. The broad ligament covers the uterus, ovaries, oviducts, and fallopian tubes. Its primary function is to hold the uterus in its position within the pelvis and maintain the relationship of the fallopian tubes to the ovaries and the uterus (which plays a vital role in reproduction).
Broad ligament pain is a sharp, deep, stabbing, or stretching sensation that worsens with movement. Some triggers may include taking a step or rolling over in bed. The broad ligament contains the nerve supply, lymphatics, and blood vessels to the female pelvic organs.
It is divided into three parts-
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Mesometrium (the largest portion).
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Mesosalpinx (mesentery of the fallopian tubes).
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Mesovarium (the connection between the ovaries and the broad ligament).
What Are the Various Disorders of Broad Ligament?
The following broad ligaments disorders can be commonly seen-
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Anatomic Defects and Internal Herniation- Broad ligament can have anatomic effects either acquired or present by birth. The factors that cause these defects can be trauma during pregnancy or delivery, endometriosis, pelvic inflammatory disease, or pelvic surgery. The defects are usually unilateral but can occur bilaterally, also.
According to Hunt, the defects can be-
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The fenestra type (defect involves both layers and creates an open window anterior to posterior).
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The pouch type (defect only involves one layer)
According to Cilley et al., the defects can be-
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Type I- involves the whole broad ligament.
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Type II- involves mesosalpinx and the mesovarium.
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Type III- mesoligamentum teres.
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Type IV- involves mesosalpinx. (added later by Fafet et al.)
The internal herniation of broad ligaments is very rare. It can involve the small bowel, ileum, or colon. Herniation can occur from anterior to posterior or in the opposite direction. The herniated loop can push the uterus to the opposite side. Severe cases need surgical intervention.
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Broad Ligament Laceration (Allen-Masters syndrome) - Allen Masters syndrome occurs due to lacerations of the broad ligament. The symptoms include persistent pelvic pain, dyspareunia (genital pain), and menstrual disturbances.
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Broad Ligament Hematoma - It occurs due to a tear extending from the upper vagina, cervix, or uterus into the uterine or vaginal arteries. The hematomas can occur during operative delivery, trauma, surgeries like dilatation and curettage (D&C), or spontaneous vaginal delivery. The risk is higher in people with congenital coagulopathy.
Broad ligament hematomas can cause large volumes of blood loss by dissecting into the retroperitoneal spaces. The broad ligament hematoma can be due to venous, arterial, or both sources. Arterial bleeding results in a rapidly expanding hematoma, whereas venous bleeding has a slower expansion rate. Broad ligament hematoma can be treated conservatively with blood transfusion and fluid resuscitation or with surgical exploration and evacuation.
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Broad Ligament Ectopic Pregnancy - It is a very rare but life-threatening type of ectopic pregnancy with high maternal morbidity and mortality. It is also known as intraligamentary pregnancy.
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Parametritis - It is the infection of the parametrial tissues occurring as a result of pelvic inflammatory disease.
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Endometrioma and Endometriosis - The posterior part of the broad ligament can be affected by endometriosis, especially in the presence of endometrioma.
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Broad Ligament Tumors - Primary tumors in the broad ligament are rare but secondary involvement of the broad ligament by malignant tumors arising elsewhere in the abdomen and pelvis is common.
The following types of tumors can be present in the broad ligament-
1. Leiomyoma - It is the most common neoplasm found in the broad ligament. This tumor can arise from the tissue that contains smooth muscle cells. It can arise in the ligaments and connective tissue in the broad ligament. These tumors are similar to those of the uterus, so they can only be diagnosed when separated from the uterus. If leiomyoma tumors grow very large, the anatomy of the pelvis gets distorted, and it compresses the ureter, which can cause hydronephrosis.
2. Leiomyosarcoma - Primary leiomyosarcomas of the broad ligament are extremely rare. They are very similar to uterine leiomyosarcomas and present as large solitary masses with areas of hemorrhage and areas of necrosis.
3. Epithelial Tumors of Müllerian Type - These are the most common type of epithelial neoplasm of the broad ligament. They can be benign, intermediate, or malignant in severity. The broad ligament cysts and ovarian cysts show very similar signs and symptoms. Some examples of these epithelial tumors are borderline serous tumors (tumors of low malignant potential) and serous cystadenoma (unilateral and unilocular cysts).
4. Wolffian Tumor or Adnexal Tumor of Probable Wolffian Origin - These are very rare benign epithelial tumors of mesonephric origin. These tumors arise within the leaves of the broad ligament or can be suspended from it. Most cases are unilateral and generally incidental findings.
5. Papillary Cystadenoma - It is a benign cystic tumor of mesonephric origin and characteristic in patients with von Hippel-Lindau disease. It develops in the broad ligament near the fallopian tube (the mesosalpinx). It is usually present unilaterally.
6. Fibroma - It is rarely present in the broad ligament. It is difficult to differentiate it from an ovarian tumor or a subserosal leiomyoma.
7. Müllerianosis - It is a benign tumor-like lesion but is different from endometriosis.
8. Secondary Malignancies - Broad ligaments can develop secondary malignancies due to metastasis from cervical, endometrial, and ovarian carcinoma and other tumors (not arising in the female reproductive organs).
Conclusion:
Broad ligament disorders are rare, but some can be life-threatening. It is one of the causes of extreme pelvic pain and irregular menstruation in females. It also impacts the reproductive system due to the involvement of all pelvic organs. Therefore, surgery is the choice of treatment for these disorders.
