The rare case of De Garengeot hernia: femoral hernia containing perforated appendicitis

Abstract

Femoral hernias account for ~4% of all groin hernias but are much more common in females, especially those over the age of 70. Risk of incarceration is overall low but can include structures such as bowel, omentum, bladder, ovary and very rarely, the appendix. The subset of femoral hernias containing the vermiform appendix is known as de Garengeot hernias. We describe a rare case of an 87-year-old female patient who presented with an incarcerated right femoral hernia confirmed on contrast-enhanced computed tomography scan of the abdomen and pelvis, with subsequent open hernia reduction revealing a perforated necrotic appendix with pus contained in the hernia sac. Histopathology revealed acute appendicitis with increased stromal fibrosis suggestive of a chronic process. Pre-operative diagnosis of de Garengeot hernias remains challenging due to their non-specific presentation and attenuated clinical symptoms, and most diagnoses are made intraoperatively.

De Garengeot hernia doubly complicated: A case report

“…The preoperative diagnosis remains challenging since the clinical manifestations of De Garengeot's hernia are non-specific [9] , and generally, the diagnosis is incidentally made intra-operatively. Physical findings include a non-reducible inguinal bulge associated with abdominal pain [7] , [10] , and local inflammatory signs are reported in one-third of the cases [11] .…”

Unusual case of De Garengeot hernia: femoral hernia containing purulent appendicitis in a 69-year-old man

“… 2 If the hernia sac is irreducible, a second incision using McEvedy’s high approach can facilitate reduction of the hernia after division of the lacunar ligament. 9 , 10 McBurney incision and subumbilical midline laparotomy are also common additional incisions. 2 Based on the surgeon’s expertise, laparoscopy can be attempted and converted to open surgery if a more complicated hernia is found.…”

Symptomatic lump during lockdown – A case of de Garengeot’s hernia

“…The femoral ring is narrow which increases the risk of incarceration of hernias that traverse it [ 10 ]. Proposed migration of the appendix in a femoral hernia include a large caecum pushing the appendix into the femoral canal, a caecum positioned low in the pelvis or an abnormal intestinal rotation during embryological development [ 11 , 12 ]. The appendicitis resulting from incarceration at the hernia neck rather than by appendicoliths [ 10 ].…”

“…Presentation is variable which at times lead to delayed diagnosis, in a recent meta-analysis by Linder et al the most common finding was a mass in the inguinal region, occurring in 96% of patients [ 10 ]. Peritonism and systemic symptoms due to underlying appendicitis is limited due to the nature of the femoral canal which keeps the ongoing inflammatory process isolated [ 12 ]. Thus, on presentation, many patients have normal inflammatory markers, and elevated laboratory tests showed no relation to the presence or duration of symptoms [ 10 ].…”