De Garengeot's Hernia: Two Case Reports with Correct Preoperative Identification of the Vermiform Appendix in the Hernia

The de Garengeot hernia chicken-and-egg conundrum: Acute appendicitis in an incarcerated femoral hernia, but which came first? A case report

INTRODUCTION

De Garengeot hernia is exceedingly rare and denotes a femoral hernia containing the appendix, which may or may not be inflamed. Given its low incidence, there is no clear consensus on the ideal surgical management of a de Garengeot hernia.

PRESENTATION OF CASE

This is a case report of an 81-year-old man who was admitted and operated on for a strangulated femoral hernia containing an inflamed appendix. Appendicectomy and primary hernia repair were performed in tandem using a single incision.

DISCUSSION

The case presented here provides a unique account of a subacute presentation of a de Garengeot hernia. It draws into question the true pathogenesis of appendicitis in this clinical setting, by lending credence to the theory that appendicitis can arise sporadically within a long-standing de Garengeot hernia, given the subacute-on-chronic nature of the patient's presentation. Furthermore, the case presented herein represents the minority of cases in which the diagnosis is clinched preoperatively based on computer tomography imaging as, in the vast majority of cases, definitive diagnosis is not made until the time of operation.

CONCLUSION

Due to the lack of prospective studies and randomised controlled trials, a standardised, evidence-based approach for the optimal surgical management of de Garengeot hernias remains elusive. Early recognition and diagnosis as well as an individualised approach that considers the patient's anatomy and clinical status are crucial to the management of De Garengeot hernias.

Appendix-preserving elective herniorrhaphy for de Garengeot hernia: two case reports

BACKGROUND

Emergency appendectomy is often performed for de Garengeot hernia. However, in some cases, there may be a chance to perform an appendix-preserving elective surgery.

CASE DESCRIPTION

A 76-year-old woman presented to our hospital with complaints of a right inguinal swelling, which we diagnosed as a de Garengeot hernia using computed tomography (CT). B-mode ultrasonography (US) of the mass showed an appendix 4-6 mm in diameter with a clear wall structure; color Doppler US showed pulsatile blood flow signal in the appendiceal wall. Twenty-eight days later, herniorrhaphy with transabdominal preperitoneal repair (TAPP) was performed without appendectomy. Another 70-year-old woman presented to our hospital with complaints of a painful bulge in the right inguinal region. The diagnosis of de Garengeot hernia was made using CT. B-mode US showed an appendix 5 mm in diameter with a clear wall structure. Color Doppler US showed a pulsatile blood signal in the appendiceal wall. Seven days later, herniorrhaphy with TAPP was performed without appendectomy.

CONCLUSION

De Garengeot hernia is often associated with appendicitis; however, an appendix-preserving elective herniorrhaphy can be performed if US and intraoperative findings do not suggest appendicitis or circulatory compromise in the appendix.

An unusual reason for an inguinal swelling: De Garengeot's hernia

We present the case of a 71-year-old female with an inguinal swelling. Intra-abdominally the appendix was found in a femoral hernia sac (De Garengeot’s hernia). A laparoscopic transabdominal preperitoneal hernia repair procedure was performed with uneventful post-operative course.

Clinical presentation of this type of hernia is unspecific and often not to be distinguished from a common incarcerated hernia. Computed tomography can be helpful in obtaining a diagnosis, although the definite diagnosis is mostly found intraoperatively. As surgical options are numerous, there is no consensus on the most suitable one. A laparoscopic approach incorporates the benefit of a total abdominal overview and the possibility of standard procedures. If the appendix appears normal, the use of synthetic mesh is considered safe and an incidental appendectomy is not necessarily required.

Femoral hernia with vermiform appendix herniation: a case report and review of the literature

Femoral hernias constitute 2–4% of all groin hernia repairs. Herniation of the vermiform appendix into the femoral hernia sac is rare. The majority of patients with appendix hernias are asymptomatic and diagnosis is made intraoperatively. We report about a case of a female patient presenting with an irreducible right-sided femoral hernia without symptoms.

De Garengeot hernia: a systematic review

BACKGROUND

A De Garengeot hernia is a femoral hernia that contains the appendix. This rare type of hernia was first described by René-Jacques Croissant De Garengeot in 1731. Numerous case reports have been published since then, yet collective analysis about the presentation, diagnosis, management, and outcomes of patients with this unique hernia is lacking.

METHODS

A systematic review was performed using PubMed, Google Scholar, Embase, and Web of Science for cases of De Garengeot hernias. Keywords searched included "De Garengeot hernia" OR "femoral appendicitis" OR "femoral hernia appendix" OR "crural hernia appendix." To facilitate review, a classification system was created based on the gross appearance of the appendix and related structures in the femoral hernia.

RESULTS

Two hundred and twenty-two cases were identified in 197 manuscripts. Cases most commonly came from Europe but have been reported worldwide. There was a female predominance (n = 180, 81.1%) and the mean age at presentation was 69.8 years. The most common presenting symptoms were a groin bulge and groin tenderness (82.4%, n = 183 and 79.7%, n = 177, respectively). A groin bulge was observed on physical exam in 95.0% (n = 211) of cases, and erythema over the hernia was present in 33.3% (n = 74). A pre-operative diagnosis of a De Garengeot hernia was established with imaging in only 31.5% (n = 70) of cases. The most common surgical approach was through a groin incision. Complications occurred in 9.5% (n = 21) of cases, most commonly surgical site infections. The most common condition of the appendix was congested/inflamed, found in 44.1% (n = 98) of cases and corresponding to class 2A in the classification system devised.

CONCLUSIONS

Overall, De Garengeot hernias were found to be rare and clinically heterogeneous, as highlighted by our classification system. A systematic approach to categorizing this unique hernia may improve management decisions and help avoid complications.

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.

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's hernia with appendicitis-a rare cause of an acutely painful groin swelling

De Garengeot hernia is a rare subtype of femoral hernia whereby the vermiform appendix is located within the hernial sac. Even rarer is the presence of appendicitis within the hernia sac. De Garengeot’s hernia is difficult to diagnose pre-operatively and can prove technically difficult at operation particularly with regards to mobilization of the caecum and appendix in order to perform appendicectomy. Laparoscopic, open, with and without mesh repair of de Garengeot hernia have all been described in the literature with varying degrees of success. We present a case of an 82 year old lady presenting with an acutely painful right sided groin lump. CT scan revealed the presence of de Garengeot hernia with acute appendicitis. We describe in text and photo format our approach to the hernia repair, appendicectomy and provide a short review of the literature with regards to the different operative approaches to such a patient.

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.

A Rare Case of Chronic Appendicitis Superimposed on an Incarcerated de Garengeot Hernia Prospectively Identified on Computed Tomography

The de Garengeot hernia is an uncommon and potentially confounding pathologic process in which the appendix is contained within a femoral hernia. While typically a benign incidental finding, superimposed acute appendicitis is a rare but serious complication. Identification of this entity is crucial to patient management and ultimately outcome with imaging playing a critical role. Cross-sectional imaging, with either CT or MRI, should be performed in all cases of suspected incarcerated de Garengeot hernia to facilitate the appropriate diagnosis and surgical intervention. Herein, we present the fifth case of a prospective CT diagnosis of the de Garengeot hernia in a 61-year-old female who presented with an irreducible right femoral hernia. The patient underwent CT examination which demonstrated the appendix within the femoral hernia sac with an associated periappendiceal fluid collection. The patient was taken for emergent surgical intervention at which time the appendix was found within the hernia sac. The appendix was removed, the defect repaired, and ultimately the patient recovered well.

De Garengeot's hernia: a rare presentation of the wandering appendix

A hernia is defined as a protrusion of an organ or its fascia through a sac of its containing cavity. The presentation of an inflamed appendix inside an incarcerated femoral hernia is termed de Garengeot's hernia. Almost exclusively seen in the female patient, this type of hernia like all others can undergo strangulation leading to complications including appendicitis with or without perforation. Management as described in literature usually comprises open or laparoscopic approach, followed by appendectomy and repair of the femoral hernia with or without mesh. We describe a case of a female patient who presented with an irreducible groin swelling, found to have a femoral hernia containing the inflamed appendix intraoperatively and how it was managed surgically through a laparoscopic approach with a small mesh and closure of defect. Literature review on this rare form of hernia is discussed thereafter.