De Garengeot's hernia: diagnosis and surgical management of a rare type of femoral hernia

Minimally invasive management of de Garengeot hernia with staged robotic hernia repair

De Garengeot hernia is a rare phenomenon describing the migration of the appendix into a femoral hernia sac. Many repair strategies have been described although an open inguinal approach with suture repair is the most common technique. Despite strong evidence that mesh limits recurrence, most forgo mesh use in the presence of appendicitis for fear of contamination. We report a case in a 68-year-old man managed completely with minimally invasive strategies. We performed a staged laparoscopic appendectomy followed by robotic hernia repair with polypropylene mesh. This is the first described two-stage minimally invasive approach and the first report demonstrating the feasibility of robotic hernia repair in the setting of de Garengeot hernia. It is our opinion that using a staged approach may encourage mesh repair by minimising the risk of implant contamination. Furthermore, we believe a fully minimally invasive technique may result in improved outcomes.

Appendix-Sparing Transabdominal Preperitoneal Laparoscopic Hernioplasty for a De Garengeot’s Hernia: Video Demonstration

Background and Objectives: Less than 300 cases of a De Garengeot’s hernia have been published. This rare femoral hernia with the vermiform appendix included appears almost exclusively on the right side, mainly in females, and it generally debuts as an incarcerated femoral hernia. Although most of the times there is a concomitant appendicitis, clinical signs of peritonitis are absent. The wide use of radiologic exams has not favored its preoperative diagnosis, but been usually found incidentally during a surgical emergency. The best surgical approach to a De Garengeot’s hernia is not totally defined and many critical questions still remain unanswered. Open surgery is considered the standard treatment procedure, but since the emergence of laparoscopy for incarcerated hernias, this is certainly an option.

Methods: We report the successful laparoscopic management of an 83-year-old woman who had been operated on her right inguinal hernia, with a Rutkow-Robbins’ technique, 4 months earlier. She had noticed the protrusion of a lump in her right inguinal region for 2 months. Radiological studies were not conclusive. With a miss diagnosis of a recurrent incarcerated inguinal hernia, a minimal invasive endoscopic approach was performed. A representative case of this fully laparoscopic TAPP procedure is presented.

Results: The patient made an uninterrupted recovery. She left the hospital the day after in a stable condition and has enjoyed good health since.

Conclusion: A fully laparoscopic TAPP approach seems perfectly safe and feasible to treat this entity, and could be considered the first line alternative when enough expertise is available.

De Garengeot hernia: a rare case in an elderly woman and a review of operative approaches

De Garengeot hernia is a rare finding of the vermiform appendix inside a femoral hernia sac. We report this occurrence in a 73-year-old woman who presented in the acute setting. There are no standardised surgical approaches and many different techniques have been described in case reports in the literature. We conducted a literature review of and found a total of 113 cases with addition of our case 114 unique cases were included for analysis. Inguinal incision was most cited (n=89). Concomitant laparotomy was needed in 13 patients, however, the association between type of incision and additional laparotomy was not significant (p>0.05). Laparoscopic surgery alone was performed in eight patients. Nine patients had hybrid surgery. The most common hernia repair was through suture technique with non-absorbable material (n=31). Mesh repair was used in 28 cases. More laparoscopic surgeries were done when the disease was diagnosed preoperatively (7/39, p<0.05).

De Garengeot's hernia in an elderly woman as a diagnostic challenge: a review of literature

De Garengeot's hernia is the presence of an appendix in a femoral hernia and can be a rare cause of an acute groin swelling. Here, we present a case report of an elderly woman who was referred to us with a short history of a painful, tender lump in the right groin associated with nausea and vomiting. Her inflammatory markers were raised, and to establish a final diagnosis, an urgent CT scan was requested which showed a blind ending tubular structure in a hernia sac. She was taken to the theatre for urgent exploration of the groin which revealed that it was a femoral hernia, the sac of which contained gangrenous appendix, the base of which could not be accessed through the groin incision and, therefore, a lower midline laparotomy incision was made and a formal appendicectomy was done.

A combined open and laparoscopic technique for the management of De Garengeot's hernia with acute appendicitis: A case report

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De Garengeot’s hernia is a rare type of femoral hernia containing the vermiform appendix. The findings of an incarcerated inflamed appendix within the hernia sac is a very rare phenomenon.

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Due to its rarity, there is no standard surgical approach to the appendicectomy and femoral hernia repair. Infact multiple approaches have been described in the literature. Approaches include an open approach, a combined open and laparoscopic approach or an entire laparoscopic approach. Decision making is multifactorial and is dependent on anatomy, intraoperative findings, patient co-morbidities and local expertise.

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Combining an low open inguinal approach followed by a laparoscopic appendicectomy is a feasible approach in the management of De Garengeot’s hernia. An initial open inguinal approach allows you to assess the hernia sac contents and avoid additional incisions if both the hernia repair and appendectomy can be safely carried out through the incison. If further incisions are required to carry out the appendectomy, a hybrid laparoscopic may be advantageous.

Introduction

De Garengeot’s hernia is a rare type of femoral hernia which describes the vermiform appendix incarcerated within the hernia sac. In this case report we present our case and review the surgical approaches described in the literature.

Presentation of case

We present the case of an 84-year-old female with a background of Parkinson’s Disease who presented to the emergency department with a five day history of a right-sided groin lump with worsening pain, nausea and reduced appetite. Computed tomography of the abdomen and pelvis revealed an inflamed appendix herniating through the right femoral canal. She had a two staged surgical approach involving an open repair of her femoral hernia followed by laparoscopic appendicectomy.

Discussion

Due to its rarity, there is no standard surgical approach to the appendicectomy and femoral hernia repair. Multiple approaches have been described in the literature, however most reports describe a simultaneous femoral hernia repair and appendicectomy. If an additional abdominal incision is required to complete the appendicectomy safely, we advocate the consideration of a hybrid open-laparoscopic approach, particularly in patients such as this with a history of Parkinson’s disease.

Conclusion

Here we highlight the usefulness of combining an open low inguinal approach followed by a laparoscopic appendicectomy.

Ultrasound diagnosis of acute appendicitis complicating De Garengeot's hernia

De Garengeot's hernia is a rare condition defined by the herniation of the vermiform appendix within a femoral hernia sac. We report a case of an 80-year-old woman admitted to our emergency department complaining of pain in the right groin. This symptomatology, present for 2 days, increased in the following 12 h. Ultrasonography (US) and contrast-enhanced computed tomography (CECT) were performed, which showed the herniation of the vermiform appendix in the femoral hernia sac. Doppler ultrasonography (DUS) and CECT were the fundamental imaging investigations for this diagnosis. The management of De Garengeot's hernia is surgical through herniorrhaphy, which makes it possible to repair the femoral hernia and perform an appendicectomy in case of appendicitis.

De Garengeot Hernia Diagnosed with Point-of-care Ultrasound

De Garengeot hernias, defined as a femoral hernia containing the appendix, are rare. It is even uncommon to have an incarcerated de Garengeot hernia with associated acute appendicitis. We report a case of a 76-year-old female presenting to the emergency department for a right lower quadrant abdominal mass for four days. Physical exam was consistent with an incarcerated hernia. A point-of-care ultrasound revealed a non-compressible, blind-ended loop of bowel within the hernia sac, concerning for acute appendicitis within the mass. Computed tomography of the abdomen and pelvis confirmed the diagnosis of acute appendicitis within a femoral hernia.

Treatment of de Garengeot's hernia: a meta-analysis

Purpose

de Garengeot’s hernia is a rare entity in which the appendix is located within a femoral hernia and is almost invariably encountered incarcerated in an emergency setting with concomitant appendicitis. In the literature, there are mostly single-case reports. The purpose of the present study was to perform a review of the literature to study the incidence, pathogenesis, demographics, clinical presentation, laboratory and radiological investigations, differential diagnosis, delay in diagnosis and treatment, operative findings, surgical technique, histological findings, the postoperative course, use of antibiotics, and complications regarding de Garengeot’s hernia.

Methods

A literature search was performed through PubMed with the following search terms, single or in combination: Garengeot, femoral hernia, and appendicitis. Additional references were also found within the articles, and two patients from Uppsala University Hospital were added.

Results

Between 1981 and 2016, 70 publications were identified, and with the additional two patients, the present series comprised 90 patients There were 75 women (median age 73.0 years) and 15 men (median age 78.0 years). On examination, an inguinal mass was found in 87 patients (97%), which was painful and the cause of primary complaint in 67 patients (74%): the median duration of symptoms was 3 days. Radiological investigations or ultrasound were performed in 67 patients (74%); computed tomography was the most accurate with a positive diagnosis in 23/34 patients. Appendicitis was found in 76 patients, gangrenous in 23, and perforated in 9. The surgical approach was inguinal in 76 patients, including 15 with concomitant laparotomy. The preperitoneal route was chosen in six patients, and laparoscopy alone in four patients. A mesh/plug was used in 22 patients (7/22 normal appendix) and suture repair in 59 (4/59 normal appendix: p < 0.01). Complications were analysed in 79 patients and occurred in 11%. There was no mortality.

Conclusions

de Garengeot’s hernia is rare, being indistinguishable from an incarcerated femoral hernia in general. A delay in surgery should be avoided but if needed, computed tomography may be used for differential diagnosis. Although there is no standard treatment, mesh material does not appear advisable in the presence of a perforation, and it is beneficial for the surgeons to perform their routine method rather than a specific technique.

Atypical presentation of a de Garengeot Hernia: A Case Report

Introduction: An inflamed appendix found within a femoral hernia, a de Garengeot hernia, is a rare occurrence which can present with a variety of different symptoms and be a challenge to surgical management. Case Presentation: We present the case of a 59-year-old female who presented with migratory right lower quadrant pain and was found to have a de Garengeot hernia diagnosed pre-operatively on CT imaging. She was taken to the OR for an urgent laparoscopic appendectomy with closure of the femoral hernia sack. Given this is not a true repair, the patient was scheduled for an elective femoral hernia repair subsequently. Discussion: This is the first report of a de Garengeot hernia from the Toronto area. Our case is the first of its kind to present with typical signs of appendicitis without any obvious bulge in the groin. Conclusion: This case report describes two very common acute surgical presentations, appendicitis and incarcerated hernia, seen simultaneously with only one rare pathology.

De Garengeot's Hernia: Report of a Rare Surgical Emergency and Review of the Literature

This is a report of a case who was admitted and operated on for a strangulated femoral hernia. The hernia sac contained a gangrenous appendix, which was excised and the hernia was repaired with sutures without complication. De Garengeot's hernia, although very rare, should be included in the differential diagnosis of cases with strangulated hernia and should receive the optimal treatment.

Diagnosis and operative management of a perforated de Garengeot hernia

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A de Garengeot hernia is a femoral hernia containing the appendix.

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Diagnosis of a de Garengeot hernia is difficult and often made intra-operatively.

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Incarceration or strangulation tends to be the clinical presentation of a de Garengeot hernia.

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It is important to have a high clinical suspicion for a de Garengeot hernia in patients with incarcerated or strangulated right femoral hernias.

Introduction

A de Garengeot hernia, a femoral hernia containing the appendix, is a difficult diagnosis often made intra-operatively when the hernia sac is opened. It is a rare finding, and complications are more frequent with a de Garengeot hernia.

Presentation of case

A 92 year-old female presented to the emergency department (ED) complaining of abdominal pain. A computed tomographic (CT) scan of the abdomen and pelvis demonstrated a hernia anterior to the inguinal ligament without strangulation. Two weeks later the patient returned to the ED with worsening abdominal pain in the right lower quadrant. Repeat CT scan demonstrated a 7 × 4 cm complex fluid collection in the right inguinal region, and the patient was taken to the operating room for exploration. The hernia sac was entered and found to contain the appendix with evidence of distal perforation. The appendix was taken out, and the hernia defect was repaired. The patient tolerated the procedure well.

Discussion

Femoral hernias have a high risk of incarceration due to the tightness of the femoral canal (Talini et al. 2015 [4]). Due to anatomic location of the appendix, de Garengeot hernias are most often seen on the right. Incarceration of the appendix is a clear etiology for appendicitis secondary to ischemia.

Conclusion

Full preoperative workup for a femoral hernia often fails to diagnose the presence of the appendix within the hernia. It is important to have a high clinical suspicion for a de Garengeot’s hernia in patients with incarcerated or strangulated right femoral hernias.

De Garengeot's hernia: an unusual case on call

De Garengeot's hernia is defined as a femoral hernia that contains the appendix. Owing to the extreme rarity of de Garengeot's hernia, it could represent a diagnostic challenge; however, it should remain in the differential diagnosis, particularly in this patient demographic. A female patient aged 96 years, who presented as an emergency with acute right iliac fossa pain, was found to have de Garengeot's hernia. The diagnosis was made intraoperatively, where she was treated with an appendicectomy and repair of the hernia defect. The incidence of de Garengeot's hernia is 0.5-5% and the incidence of appendicitis within a femoral hernia is extremely rare. Preoperative diagnosis is challenging to the treating surgeon, which requires a high index of suspicion and is usually made intraoperatively. There is no standard treatment; however, simple appendicectomy and hernia repair seems to be an accepted management.

De Garengeot hernia with perforated appendicitis and a groin subcutaneous abscess: A case report

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De Garengeot hernia with a groin subcutaneous abscess is rare.

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Appendectomy and herniorrhaphy via the same incision may be more effective.

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Clinicians should consider de Garengeot hernia in patients with a groin hernia.

Introduction

De Garengeot hernia is rare. Although previous reports have suggested various surgical options according to patient condition, comorbidities, surgeon preference, and clinical findings during surgery, a treatment strategy has not been established.

Presentation of case

An 81-year-old woman presented with an irreducible tender mass that was subsequently diagnosed as an incarcerated femoral hernia with a subcutaneous abscess in the right groin. Intraoperative findings revealed a necrotic and perforated appendix strangulated by the femoral ring for which an appendectomy and herniorrhaphy was performed concurrently through the hernia sac. The subcutaneous abscess cavity was washed thoroughly and a drainage tube was placed within it. The patient recovered uneventfully.

Discussion

We suggest that the approach through the inguinal incision in both appendectomy and herniorrhaphy with drainage may be useful in avoiding intra-abdominal contamination in cases of de Garengeot hernia with subcutaneous abscess.

Conclusion

Here, we described a case of de Garengeot hernia with a subcutaneous abscess in the groin. Clinicians should consider de Garengeot hernia in patients with a groin hernia, make an early diagnosis, and promptly provide surgical treatment to reduce the risk of complications.

Case Report: De Garengeot's hernia. Appendicitis within femoral hernia. Diagnosis and surgical management

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The presence of the appendix inside a femoral hernia is called De Garengeot’ s hernia.

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Diagnosis is usually as an incidental findings intra operative.

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We present a case of appendicitis on a strangulated femoral hernia, with pre-operative diagnosis.

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We were able to reduce appendix by laparoscopy approach and later on perform open repair of femoral hernia.

Introduction

Abdominal wall hernias remain as one of the most common problems that the general surgeon has to treat. Although usually straightforward and easy to diagnose by the experienced hands, obstacles appear when contents of the hernia sac include organs. The presence of the appendix inside a femoral hernia (De Garengeot’s hernia) is a rare entity which represents multiple challenges, both diagnostic and therapeutic.

Case presentation

We present a case of a 36-year-old female patient who originally presented to the ED with abdominal/groin pain and a new onset of right inguinal swelling.

Discussion

Contrary to the usual presentation, where an appendix is incidentally found during hernia repair, we were able to make the diagnosis by CT scan before surgery. This placed us on an ideal standpoint to plan the surgical management. We approached our case laparoscopic first, where a distally gangrenous appendix was reduced intraabdominally. As purulent exudates were present on hernial sac, femoral hernia repair was achieved with McVay techniche.

Conclusion

Although rare, the finding of a strangulated appendix within a femoral hernia represents a challenge. Here we present a case that may guide the surgeon who faces a similar case in the future.

De Garengeot's hernia in an 82-year-old man: a case report and clinical significance

The presence of the appendix within a femoral hernia (FH) sac is known as Garengeot's hernia (GH). We report on current study a rare case of an elderly man with a combined inguinal and Garengeot's hernia and discuss the clinical aspects. An 82-year-old man clinically stable, presented history of pain at the right inguinal region for over a week, without vomit, nausea, fever or any alteration of intestinal or urinary eliminations. Clinical examination revealed a FH and the ultrasonography confirmed the hernia sac. During the surgery, the appendix was recognized within the sac, and then, the patient underwent appendectomy and hernia repair. In conclusion, the presence of the vermiform appendix in a FH sac is rare, thus, requiring knowledge of the surgeon regarding this clinical entity. Prompt diagnosis and appropriate surgical treatment is the key to avoid complications.

Treatment of De Garengeot's hernia using De Oliveira's technic: A case report and review of literature

INTRODUCTION

The French surgeon Rene Jacques Croissant de Garengeot first described the finding of the Appendix inside a femoral hernia sac in 1731. The De Garengeot's hernia is a rare entity, comprehending only 0.5-5% of the femoral hernias. The pathogenesis of this entity is still controversial, and in the same way, there are different theories to explain the occurrence of appendicitis inside the De Garengeot's hernia. There is no standard technique in the treatment of this entity.

PRESENTATION OF CASE

W.P.S., 84, female, admited for medical assistance due to claims of edema and flogistic signs in the right inguinal region, noted four days prior. There was no abdominal pain, discomfort, or other symptoms. The physical examination showed hard edema and bulging on the right inguinal region, colaborating for the hipotesis of incarcerated hernia. Patient was then submitted to inguinotomy and the vermiform Appendix was discovered inside the femoral hernia without signs of appendicitis. The case was conducted using the De Oliveira's technique to femoral hernia repair and Liechenstein for the inguinal hernia repair.

DISCUSSION

The De Garengeot's hernia is a rare entity, comprehending only 0.5-5% of the femoral hernias(2), it represents an unusual finding and is, in the majority of cases, diagnosed intraoperatively. It's pathogenesis is yet matter of discution. There is no standard approach for this hernia, possibly by the few numbers and variability of presentation of cases described.

CONCLUSION

This paper presents a case of a 84yo female with De Garengeot's hernia that was submitted to a correction using the De Oliveira's technic. A low cost technic with great results without use of polypropylene mesh.

Garengeot's hernia: two case reports with CT diagnosis and literature review

Garengeot's hernia (GH) is defined as the presence of the appendix inside a femoral hernia. It occurs in 0.9% of femoral hernias and is usually an incidental finding during surgery. Its treatment is controversial and the aim of this article is to review the diagnostic methods and surgical considerations. We report two cases diagnosed preoperatively by contrast-enhanced computed tomography (CT) and discuss the treatment options based on a review of the literature published in PubMed updated on 1 December, 2015. Fifty articles reporting 64 patients (50 women, mean age 70 years) with GH were included in the analysis. Diagnosis was performed by preoperative CT in only 24 cases, including our two. The treatment of GH is emergency surgery. Several options are available laparoscopic or open approach: insertion of a mesh or simple herniorrhaphy, with or without appendectomy.

CONSLUSION

The preoperative diagnosis with CT can guide the choice of treatment. Appendectomy and hernioplasty should be performed via inguinotomy, if there is no perforation or abscess formation.

A case of De Garengeot hernia requiring early surgery

De Garengeot hernia is a rare clinical entity defined as the presence of a vermiform appendix within a femoral hernia sac. A 50-year-old woman presented to the emergency department with a painful lump over her right groin region. A bedside ultrasound was performed and soft tissue lesion was suspected. CT was performed and revealed a swollen tubular structure with fat stranding within the mass. De Garengeot hernia with acute appendicitis was diagnosed preoperatively, and an emergency appendectomy and hernioplasty were performed. Although it is usually an incidental finding during hernioplasty, De Garengeot hernia should be considered in the differential diagnosis of patients with an incarcerated femoral hernia. Mesh repair can be performed depending on the clinical situation. We report a rare case of incarcerated femoral hernia with acute appendicitis that required early surgical management to avoid associated complications.

Amyand hernia: Case report and review of the literature

Introduction

Amyand Hernia is a rare disease seen in approximately 1% of all hernias, complications of it, like acute appendicitis, or perforated appendicitis are even more rare, about 0.1%. Its diagnosis is very difficult in the pre-operative period; it is usually an incidental finding.

Presentation of case

This paper describes the case of a forty-year-old male patient, which was presented to the outpatient clinic of surgery with an incarcerated right side inguinal hernia without any signs of ischemic complications. He was admitted, and an hernioplasty was performed, as an incidental finding we encountered an Amyand hernia treated without appendectomy and placement of a prosthetic mesh without any complications.

Discussion

This disease represents a very challenging diagnosis, seven years ago the standardization of management had already been established; in this case we encountered a type 1 Amyand's Hernia so we performed a standard tension free hernioplasty without complications.

Conclusion

Amyand hernia is a rare condition, which represents two of the most common diseases a general surgeon has to face. Standardization of treatment is still ongoing and more prospective studies need to be done. This case demonstrates that this pathology must remain in the mind of the surgeons especially in the event of a strangulated hernia and offer a comprehensive review.

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A rare case of inguinal hernia.

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We document the new approach of this pathology.

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Increasing information reveals that prospective studies are needed.

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The knowledge and ability of a tension technique for hernia repair that this pathology may need.

De Garengeot's hernia: 40 years after Bassini inguinal hernioplasty

De Garengeot's hernia (DGH) is a rare entity in which the vermiform appendix is located within the femoral hernia sac. Even though DGH is known to be more common in females, we report a case of a male patient having undergone Bassini-type inguinal hernia repair over 40 years ago. We present the preoperative diagnostic measures and an example of the surgical management of this rare entity.

De Garengeot hernia: Case report and review

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We report a rare case of incarcerated femoral hernia containing the appendix inside the hernia sac (De Garengeot hernia) without appendicitis.

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The presence of the appendix within a femoral hernia sac is uncommon and is generally found only during surgery. Most times patient are taken to emergency surgery with the nonspecific diagnose of incarcerated hernia.

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The patient in this case was submitted to inguinotomy with appendectomy and hernia repair using mesh and presented good outcome, without complications or hernia recurrence.

Introduction

Rene De Garengeot, a French surgeon, was the first to describe the presence of the appendix inside a femoral hernia sac in 1731. It is a rare entity that has fewer than 100 cases reported in literature.

Presentation of case

An 86 years-old male patient, comes to Emergency Department complaining of painful bulging in the right inguinal region, associated with local inflammatory signs. He was initially diagnosed as incarcerated femoral hernia and underwent emergency open surgery. Inguinotomy was performed and after hernia sac dissection it was possible to observe the presence of the appendix incarcerated in its interior, without clinical signs of appendicitis. Surgeons performed appendectomy and inguinal repair of the femoral hernia with placement of a polypropylene mesh.

Discussion

De Garengeot hernia is a rare entity that requires early treatment in order to avoid possible complications. When facing a patient with incarcerated hernia emergency surgery must be indicated even if it is not possible to determine the contents of the hernia.

Conclusion

This paper presents a case report of a De Garengeot hernia patient who presented a good evolution after surgery.