Unusual presentation of De Garengeot hernia

Abstract

De Garengeot hernia describes a rare phenomenon in which a vermiform appendix is found in a femoral hernia sac. We describe a case of De Garengeot hernia presenting as a groin lump associated with loss of appetite, weight loss and fatigue. A 72-year-old woman was referred to our rapid access 2-week clinic as isolated lymphadenopathy with a 4-week history of a gradual right groin swelling accompanied by an unintentional weight loss, lethargy and anorexia. An urgent excisional lymph node biopsy was performed preceding the CT scan of the chest, abdomen and pelvis. The biopsy showed a shaving of appendix wall, and the CT scan revealed a right-sided femoral hernia with appendix as its content. The patient was urgently contacted for a laparoscopic appendicectomy and an open right femoral hernia repair. The patient recovered well postoperatively, and her systemic symptoms fully resolved when reviewed 10 weeks after the operation.

Background

The presence of a vermiform appendix in a femoral hernia sac is a rare phenomenon termed De Garengeot hernia.¹ It is most often found incidentally during femoral hernia repairs with an incidence in <1% of all femoral hernia cases.²

To the best of our knowledge, this is the first case of De Garengeot hernia reporting to cause non-specific systemic symptoms of loss of appetite, weight loss and fatigue resembling lymphoma in its presentation with the examination finding of a groin lump. The absence of a specific guideline for its management poses an additional challenge to the clinicians when faced with this rare condition.

Case presentation

A 72-year-old woman with COPD and hypertension presented to her general practitioner (GP) with a 4-week history of a gradual right groin swelling accompanied by an unintentional weight loss of two stones, lethargy and loss of appetite. The GP initially referred the patient to the haematologists for a suspected lymphoma with routine blood tests arranged. The haematologists however triaged the referral to the general surgeons for an urgent lymph node biopsy on the basis that isolated lymphadenopathy with normal blood count and no splenomegaly fails to meet their 2-week wait criteria.

She was subsequently reviewed by the general surgeons under the 2-week rapid access referral pathway. The patient denied any abdominal pain and her bowel movements were normal. On clinical examination, the abdomen was unremarkable and no cervical lymphadenopathy was felt. On palpating the right groin, an irreducible 1 cm subcutaneous mass was found, free from the deep planes of tissue, which felt like an isolated enlarged lymph node.

Investigations

In the view of the patient’s history and clinical examination findings, further routine blood tests, an urgent CT scan of the chest, abdomen and pelvis, and an urgent lymph node biopsy were arranged.

The routine blood tests including full blood counts, electrolytes and creatinine, liver function tests and CRP all came back within the normal range. The CT scan of the chest, abdomen and pelvis stated that there is no evidence of lymphadenopathy but a probable abscess in the right groin that is small and not amenable to drainage.

An excisional biopsy of the right inguinal lymph node was performed under local anaesthetics shortly after the clinic. At the time of the biopsy, the specimen obtained felt like a matted lymph node. However, the histology report later came back stating a microscopic appearance of fat necrosis and a normal appendix (figure 1). The CT scan was re-reviewed in light of these findings, and it showed a femoral hernia with the appendix as a content of the hernia (figure 2).

Figure 1.

Histology revealing a longitudinal section from appendix showing wall, lumen and the mucosa.

Figure 2.

CT scan showing a right femoral hernia with appendix as its content. (A) Transverse section showing the patient’s femoral hernia (arrowed). (B) Sagittal section showing the appendix (arrowed) in the femoral hernia.

Treatment

With the histological and radiological findings, the patient was urgently contacted to be brought back for emergency surgery. On review, the patient further mentioned that her biopsy wound site was not healing well with frequent discharge, indicating the formation of an infected sinus tract.

She received preoperative prophylactic antibiotics, and diagnostic laparoscopy was performed first under general anaesthesia. The diagnostic laparoscopy revealed a firmly fixed tip of the appendix to the right femoral hernia defect (figure 3). We proceeded to create a preperitoneal space by incising the peritoneum in the lower part of the abdomen. The tip of the appendix, which was firmly adherent into the femoral canal, was dissected out.

Figure 3.

Intraoperative finding of a firmly fixed tip of the appendix to the right femoral hernia defect.

After, we performed an open approach to repair the femoral hernia. An incision was made over the previous groin incision from the biopsy to get into the correct plane. The dissection was continued below the reflection part of the right inguinal ligament. The defect in the femoral canal was repaired with interrupted No. 1 Vicryl sutures. We preferred an absorbable suture over a non-absorbable suture in the view of the infection and avoided the use of a mesh.

Outcome and follow-up

The patient recovered well and was discharged 1 day after the surgery. Histopathology for the appendix came back to be normal.

At a follow-up clinic 10 weeks after the surgery, the patient was asymptomatic with a well-healed scar. She regained her appetite and had no further loss of weight postoperation. There was no recurrence of the hernia despite the absence of a mesh, and the patient was discharged from our clinic.

Discussion

A femoral hernia is the protrusion of a peritoneal sac through the femoral ring into the femoral canal. Due to the anatomy of the femoral canal, femoral hernias have a high risk of strangulation or obstruction, and its acute presentations are associated with a 10-fold increased risk of mortality.³

The femoral hernial sac may contain intra-abdominal structures such as peritoneal fat or small bowel. Rarely, a vermiform appendix is found in a femoral hernial sac. This phenomenon is known as De Garengeot hernia and accounts for 1% of all femoral hernias.⁴

The exact pathogenesis of De Garengeot hernia is unknown. Some suggest it is due to the large caecum pushing the appendix into the femoral hernia sac, whereas others suggest that it may be due to the rotation of the bowel causing an abnormal attachment of appendix to the caecum.⁵

Clinically, De Garengeot hernia has largely been reported to present in an emergency setting with patients complaining of a several-day history of a painful, irreducible groin lump with local erythematous changes.^{6 7} Most of the times, De Garengeot hernias are diagnosed intraoperatively as an incidental finding,^{2 6} with a limited number of reports suggesting a role for a preoperative CT scanning in establishing the diagnosis.^{8 9} Although there is no established guideline on its management, the general consensus is an emergency surgery with either an open or laparoscopic approach to remove the appendix and to fix the femoral hernia.¹⁰

In our case, the diagnosis was achieved while ruling out more sinister pathology due to our patient’s presentation. To the best of our knowledge, this is the first case of De Garengeot hernia reporting to cause non-specific systemic symptoms of loss of appetite, weight loss and fatigue. The pathophysiology behind this presentation is unclear, but our intervention resulted in a complete resolution of her systemic symptoms at 10 weeks follow-up. We speculate that biochemical changes from a possible constant peritoneal irritation due to the hernia could have resulted in anorexia, which in turn resulted in fatigue and weight loss.

Due to the condition’s rarity, the histology report came as a surprise, and the radiologist initially missed the diagnosis as well despite the finding being present on the cross-sectional imaging (figure 2). It was only after the surgeon and the radiologist reviewed the imaging together once again after the histology report that De Garengeot hernia was found and diagnosed. Furthermore, a patient complaining of signs and symptoms suggestive of an infected sinus following the initial biopsy is unusual following a lymph node biopsy.

There is currently no agreed guideline as to how to repair De Garengeot hernia. In our case, a sinus tract was formed following the initial biopsy, which subsequently became infected. As well as repairing the patient’s femoral hernia, the surgery had to consider the infection and the removal of the sinus tract. The operation started with a laparoscopic approach to explore and remove the appendix. After, we performed an open approach to repair the femoral hernia. An incision was made over the previous groin incision from the biopsy to get into the correct plane and the hernia was repaired with interrupted No. 1 Vicryl sutures. This resulted in a successful outcome at a 10-week follow-up.

On follow-up, there was no recurrence of the patient’s hernia. As such, we would not at the moment recommend a further operation to repair the hernia with a mesh. However, should there be a recurrence, a revision repair using the prosthetic mesh would be necessary.

Learning points.

• De Garengeot hernia can present as a non-tender small groin lump associated with non-specific symptoms of loss of appetite, weight loss and lethargy mimicking lymphoma.

• CT scan can be helpful in diagnosing De Garengeot hernia.

• Early surgical intervention is necessary for the management of De Garengeot hernia to prevent complications.

• Elderly patients with a painless groin lump associated with systemic symptoms should be thoroughly investigated.

• Groin lump exploration should be preceded by the radiological investigation.