De Garengeot Hernia: A Rare Presentation of a Femoral Hernia

AFFILIATIONS:
¹Physician Assistant, Chevy Chase Surgical Associates, Chevy Chase, MD
²Medical Assistant, Washington Institute of Surgery, Chevy Chase, MD
³Surgeon in Chief, Washington Institute of Surgery, Chevy Chase, MD

CITATION:
Donovan EJ, Cruser JC, Macey RE, Kalan MMH. De Garengeot hernia: a rare presentation of a femoral hernia. Consultant. 2023;63(4):e6. doi:10.25270/con.2022.08.000007

Received December 28, 2021. Accepted February 1, 2022. Published online August 19, 2022

DISCLOSURES:
The authors report no relevant financial relationships.

DISCLAIMER:
The authors report that informed patient consent was obtained for publication of the images used herein.

CORRESPONDENCE:
Elizabeth J. Donovan, PA-C, Washington Institute of Surgery, 5530 Wisconsin Ave Suite 1450, Chevy Chase, MD 20815 (jcruser@chevychasesurgical.com)

A 61-year-old woman presented to the emergency department with swelling and tenderness of the right groin, low-grade fever, and chills. The bulge had been present in the right groin for 2 months. Her newest symptoms began 8 days prior to presentation.

History. The patient had a medical history significant for hypothyroidism, osteoarthritis, and Lyme disease. She also had a surgical history significant for bilateral knee arthroscopy, right food Morton neuroma removal, right bunionectomy, and right rotator cuff repair.

Physical examination. The patient had right lower quadrant and right groin swelling and pain. No nausea, emesis, fever, chills, or sweating was reported. The right lower quadrant erythema had resolved. The patient was afebrile with a temperature of 36.8 °C.

Diagnostic studies. Ultrasonography examination of the right groin identified a complex cystic structure, possibly representing a hernia with associated fluid collection but not definitive for a femoral hernia.

Treatment and management. The patient was treated with oral cefalexin for cellulitis and discharged with instructions to see her gynecologist for further evaluation of the right groin cystic structure. Her gynecologist ordered a computed tomography (CT) scan of the abdomen and pelvis, which identified an inflamed appendix incarcerated within the right inguinal canal (Figures 1 and 2). As recommended by the gynecologist, the patient returned to the emergency department 1 day later for outpatient surgical evaluation. On examination, she had no nausea, vomiting, fever, or chills. A complete blood cell count evaluation showed no leukocytosis.

Figure 1. A CT scan of the abdomen and pelvis in the transverse plane showed the presence of the appendix in the right groin.

Figure 2. A CT scan of the abdomen and pelvis in the sagittal plane showed the presence of the appendix in the right groin.

The patient then underwent diagnostic laparoscopy, appendectomy, and repair of an inguinal hernia. The Hasson technique was used to enter the abdomen via a subumbilical incision. After insufflation of the abdomen, 2 additional ports were placed in the lower abdomen. The appendix was trapped within a right femoral hernia. The appendix, which appeared severely inflamed and possibly necrotic, was carefully reduced (Figures 3 and 4). The appendix was cleanly transected with an endovascular gastrointestinal anastomosis stapler, the pelvis was irrigated, and the ports were removed, concluding the laparoscopic portion of the procedure.

Figure 3. During the diagnostic laparoscopy, the appendix was trapped within a right femoral hernia.

Figure 4. During the diagnostic laparoscopy, the appendix, which appeared severely inflamed and possibly necrotic, was carefully reduced and transected.

Attention was turned to the right groin, where a firm mass was visible just below the inguinal crease. A 4-cm incision was made just above the inguinal crease. An incarcerated femoral hernia sac, and the necrotic fat contained within, were excised. A primary repair was performed to avoid using a mesh in a potentially infected space.

Following the procedure, the patient was prescribed amoxicillin-clavulanate and discharged home. The patient recovered well without complications or recurrence of the hernia within the first 6 months.

Discussion. Femoral hernias are an uncommon type of groin hernia with a high incidence of incarceration.¹ A De Garengeot hernia develops when the appendix migrates through a femoral hernia.^1-7 The name originates from Rene Jacques Croissant de Garengeot, a French surgeon who first described a case of the appendix in a femoral hernia in 1731.^1-3,5-7 It is a rare presentation that accounts for 0.5% to 3.3% of all femoral hernias.^1,3,5,6 The incidence of appendicitis within this hernia type is even rarer, with an occurrence as low as 0.08% to 0.13%.^1,4 The diagnosis is difficult to make preoperatively because of nonspecific history and clinical findings; therefore, the diagnosis is typically made intraoperatively.^1-3,5,6 The authors report a case of a chronically inflamed appendix incarcerated within a femoral hernia and its management.

Patients usually present with a painful bulge in the right groin, and an incarcerated right inguinal, femoral hernia, or acute lymphadenopathy are commonly misdiagnosed.^1,2,5 On physical examination, a tender mass or bulge in the groin is the most common sign, with erythema of the skin seen in about 33% of cases, indicating possible cellulitis.⁵ The diagnosis of an incarcerated femoral hernia often leads to emergency surgery to minimize the chance of strangulation of hernia contents.⁶ This diagnosis often leads to an open repair of a femoral hernia with an incarcerated appendix discovered intraoperatively.¹

Preoperative imaging results are usually nonspecific, but CT is the best modality to distinguish a De Garengeot hernia from other incarcerated hernias. CT scans reconstruct “air-weighted conditions” in tissues that contain intramural air.^1,3,6 The De Garengeot hernia is associated with an intramural air density in an incarcerated hernia sac visible on CT, suggesting intestinal contents.³ Typical CT results can also reveal a tubular structure within the hernia sac and adjacent fat stranding.^1,6 Preoperative diagnosis of a De Garengeot hernia on CT has been observed to be less sensitive than the diagnosis of appendicitis, because of difficulty visualizing the appendix within the hernia.^5,6

The recommended treatment for De Garengeot hernia is appendectomy and hernia repair.^1,3-5,7 Disagreement exists in the literature as to whether an appendectomy should be performed in conjunction with the hernia repair when there is a normal-appearing appendix.^4,6 When the diagnosis is made during groin exploration, the approach is typically an open groin appendectomy followed by an open femoral hernia repair through the same incision; however, there is no standard surgical approach for the repair.^1,3,5,6 The laparoscopic approach is less common because making the diagnosis preoperatively is difficult.² When the diagnosis is known, laparoscopy is employed to assess the degree of intra-abdominal infection, remove the appendix, and guide the choice of hernia repair.^5,8 The hernia repair can be approached in a delayed fashion, laparoscopically (ie, using a transabdominal preperitoneal procedure in the case of minimal appendiceal infection), or with open suture repair if there is concern for infection of mesh, especially in the presence of abscess or perforation.^3-6,8

Postoperative infection is the most common complication and occurs in 14% to 29% of cases.^1,5,6 This infection rate is increased by the suturing of multiple tissue planes in the repair of the incarcerated hernia.¹ Delayed or suture repair of the hernia rather than use of a mesh can help lower the risk of postoperative infection.^3,4,6

Limitations. The generalizability of this case is limited by the rarity of the presentation of acute appendicitis within a De Garengeot hernia. This case reports the findings for only one patient, which could also limit the generalizability of the techniques used to treat a De Garengeot hernia.

Conclusion. A De Garengeot hernia is a rare occurrence in which the appendix is present within a femoral hernia.^1-7 It can be difficult to diagnose preoperatively and is often found during open repair of an incarcerated femoral hernia.^1-3,5 Generally, treatment involves appendectomy and repair of the incarcerated femoral hernia.^1,3-5,7 Suture repair of the hernia is recommended over the use of mesh in the presence of acute appendicitis to minimize the risk of postoperative surgical site infection.^3,4,6