De Garengeot hernia: A unique presentation of femoral hernia with perforated appendicitis

Abstract

Introduction

De Garengeot hernia is a rare subset of femoral hernias containing the vermiform appendix. It is more common in females. The presenting symptoms are non-specific hence diagnosis is challenging and there is no consensus on treatment of it.

Presentation of case

An 85-year-old male patient who had previously undergone herniorrhaphy presented with a four-day history of pain and swelling in the right groin region. On a contrast-enhanced computed tomography scan it revealed incarceration of the appendix within femoral hernia. It was managed with appendectomy and closure of the defect using non-absorbable suture.

Discussion

Diagnosis of De Garengeot hernias remains challenging due to their non-specific presentation and attenuated clinical symptoms, often leading to intraoperative identification. It is crucial for physicians to recognize this rare presentation of appendicitis and be familiar with the available surgical interventions. However, the literature does not establish a consensus regarding the preferred surgical approach.

Conclusion

De Garengeot hernia remains an uncommon and challenging presentation of femoral hernia, particularly when complicated by appendiceal incarceration leading to acute appendicitis. Surgical management should be tailored to each patient's unique circumstances.

Highlights

• •De Garengeot hernia is a rare type of femoral hernia.
• •Acute appendicitis might rarely present with herniation of vermiform appendix into femoral canal.
• •There is a lack of agreement regarding the surgical approach to it.
• •Surgical strategies can be customized depending on cases.

1. Introduction

Femoral hernias occur as a result of weakening and protrusion of abdominal viscera through the femoral canal, bordered superiorly by the inguinal ligament and laterally by the femoral vessels. They constitute approximately 3–4 % of all groin hernias [1,2]. The migration of the appendix through the femoral canal is termed De Garengeot hernia, and accounts for 0.5–1 % of all femoral hernia cases [3]. This type of hernia can contain a completely healthy, inflamed, infected, unruptured or ruptured appendix [4,5]. The presence of acute appendicitis within a femoral hernia is still rarer, with an incidence of 0.08–0.13 % described in the literature [6].

The preoperative diagnosis of De Garengeot hernias is made difficult by its non-specific clinical presentation and minimal symptoms hence most patients end up being diagnosed incidentally during surgery [5]. This paper, adhering to Surgical CAse REport (SCARE) guidelines, details a unique case of an 85-year-old male who presented with an incarcerated right femoral hernia containing a perforated necrotic appendix and subsequent management [7].

2. Presentation of case

An 85-year-old male presented to the emergency department with a four-day history of pain and swelling in the right groin region. The swelling had appeared one week back, was initially painless. He had nausea but did not complain of fever, vomiting or loose stools. Notably, he had undergone herniorrhaphy 25 years ago for a right inguinal hernia. Upon examination, his temperature was 36.1 °C, heart rate 78 beats per minute, blood pressure 102/78 mm of Hg, and respiratory rate of 14 per minute. A right groin lump was found below and lateral to the level of the pubic tubercle, measuring approximately 4 × 4 cm in size which was tender, non-reducible, non-fluctuant, with overlying erythematous skin changes (Fig. 1). The abdominal examination revealed softness, absence of distension, and lack of tenderness, accompanied by regular bowel sounds upon auscultation, and no indications of bowel obstruction.

Fig. 1.

Showing swelling in groin region with overlying skin changes (green arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

The laboratory findings indicated a normal white cell count within the normal range at 7 ∗ 10^3/μL (normal range: 6–10 ∗ 10^3/μL), as well as normal electrolyte levels. Initial radiologic studies included transabdominal pelvic ultrasound, which showed a 2.4 × 2.6 cm tubular structure in the right femoral region with minimal collection around it. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis revealed a dilated tubular structure originating from the base of the caecum suggestive of vermiform appendix in the right femoral canal measuring 3.7 × 4.2 × 3.6 cm protruding through widened femoral ring. The wall of the appendix showed mild homogenous enhancing thickening with a defect near the tip suggestive of perforated appendicitis. Mild collection with few air foci was noted near the defect (Fig. 2, Fig. 3).

Fig. 2.

Contrast-enhanced sagittal (left) and axial (right) image showing tubular fluid-filled tubular structure (yellow and red arrow) herniating into the femoral region via the widened femoral ring with mild homogenous enhancing thickening of its wall. Overlying skin shows inflammatory edematous thickening. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3.

Contrast-enhanced coronal CT scan showing inflamed tubular structure (blue arrow) is medial to femoral vessels (red arrows) and is originating from the base of the caecum (maroon arrow) suggestive of inflamed appendix herniating into the femoral canal. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

The patient was placed nil per os, intravenous fluid resuscitation and antibiotic therapy was promptly initiated. Subsequently, the patient went exploratory laparotomy with low midline incision. Intraoperatively, grossly inflammed vermiform appendix was herniated within the femoral canal. Following identification of sac, surrounding tissues were dissected, and the sac was subsequently opened. Approximately 20 ml of purulent fluid was drained, and cultures were sent for sensitivity testing. The femoral hernia contained the perforated appendix, with the shaft and tip protruding through the femoral canal, while the remainder of the bowel appeared normal (Fig. 4). Subsequently, an appendectomy was performed, the cecum was repositioned into the peritoneal cavity, and the femoral defect was closed using non-absorbable sutures. The skin was then closed without leaving any drains. The patient's recovery progressed smoothly, and he was discharged on the third post-operative day. Histopathological examination confirmed the presence of acute inflamed appendicitis without any signs of neoplasm. Culture and sensitivity of pus showed growth of Escherichia coli which was sensitive to Cefixime. Patient was discharged with Cefixime 200 mg twelve hourly for one week and asked to follow up. During the two-week follow-up, the wound showed healthy healing without any indication of hernia recurrence.

Fig. 4.

On the left side, the intraoperative image depicts an open femoral hernia repair, revealing a hernia sac (highlighted by the light blue arrow) containing the appendix (indicated by the green arrow), which extends from the cecum (marked by the purple arrow). On the right side is the specimen with perforation at tip (pink arrow) following appendectomy. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

3. Discussion

The De Garengeot hernia was initially documented in 1731 by French surgeon Rene Jacques de Garengeot. There are various theoretical explanations regarding the presence of the appendix within the femoral canal mostly focusing on two factors: embryologic anomalies resulting in the pelvic appendiceal location on the cecum and an enlarged cecum, which can induce appendix herniation due to its mass effect [8,9]. The mechanism for which appendicitis develops inside the femoral canal is debated, whether the appendix migrates into the narrow, rigid femoral ring where it then becomes incarcerated and strangulated or appendicitis occurs first followed by its migration into the femoral canal [10].

The De Garengeot hernia shows a higher predisposition in women as a result of a larger femoral canal [10,11]. However, our case was a male who had prior herniorrhaphy for inguinal hernia on the same side. Prior studies have reported that prior inguinal hernia repair is considered to be at higher risk of developing De Garengeot hernia [12]. Patients usually present with a painful, irreducible right-sided groin lump without the systemic symptoms of fever, tachycardia, nausea, vomiting associated with intraperitoneal pathology as the nature of the femoral canal tends to limit the spread of sepsis into the peritoneal cavity [13]. Thus, even perforated appendicitis tends to manifest as localized tenderness rather than generalized peritonitis, delaying the patient's presentation as seen in our case [14]. The differential diagnosis should include inguinal hernia, inflammation of nearby viscera, great saphenous vein ectasia, lipoma or others soft tissue neoplasia, lymphoma and retroperitoneal abscesses [15]. Abdominal examination, laboratory tests, and plain imaging do not provide substantial assistance in making a differential diagnosis for this condition [16]. Imaging modalities also vary in their ability to detect De Garengeot hernias, with MRI being the most sensitive but usually reserved for young pregnant women. Ultrasonography is useful in non-obese patients but is operator dependent. Hence, CT scan remains the modality of choice as it can at the very least detect a herniating mass projecting below the caecum into the femoral canal with fat stranding [5,17].

Treatment consists of emergency surgery. Due to the rarity of the condition, there is no agreed consensus for surgical approach and technique [18]. Over the past two decades, there have been reports documenting the utilization of the laparoscopic approach for managing De Garengeot hernia [19]. Guenther et al. proposed a classification system based on the condition of the appendix, suggesting that cases categorized as Class 2 or higher should undergo appendectomy [16]. Since our case belongs to Guenther class V we proceeded with appendectomy, defect closure and avoided mesh in our case due to concomitant appendicitis.

4. Conclusion

De Garengeot hernia should be borne as differential in cases with groin swelling and overlying inflammed skin. Sound knowledge of embryology and femoral canal anatomy is needed in surgeons for management of this type of hernia.

Consent

Written consent obtained from all patients for publication and any accompanying images, copy of which is available for review by the Editor-in Chief of this journal on request.

Declaration

All the authors declare that the information provided here is accurate to the best of our knowledge.

Ethical approval

Since this is a case report, our Institutional Review Board Institute of Medicine (IOM) has waived the requirement for ethical approval.

Funding

This study received no funding.

Author contribution

Conceptualization: Bhawesh Bhattarai, Sujan Paudel, Prajjwol Luitel, Arjun Yadav, Akriti Dahal, Abhishek Bhattarai.

Patient Management: Bhawesh Bhattarai, Arjun Yadav, Abhishek Bhattarai.

Writing – original draft: Bhawesh Bhattarai, Sujan Paudel, Prajjwol Luitel, Arjun Yadav, Akriti Dahal, Abhishek Bhattarai.

Writing – review & editing: Bhawesh Bhattarai, Sujan Paudel, Prajjwol Luitel, Arjun Yadav, Akriti Dahal, Abhishek Bhattarai.

Visualization and Supervision: Bhawesh Bhattarai, Sujan Paudel, Prajjwol Luitel, Arjun Yadav, Akriti Dahal, Abhishek Bhattarai.

Guarantor

Bhawesh Bhattarai.

Research registration number

N/A.

Conflict of interest statement

Authors have no conflict of interest to declare.

Data availability

The datasets used during this study will be available from the corresponding author upon reasonable request.