Swelling of the right thigh for over 30 years—The rare finding of a De Garengeot hernia

INTRODUCTION

Femoral hernias may – in some rare cases – contain the appendix, a phenomenon called de Garengeot hernia. It is usually an incidental finding in hernia repair. We found our case to be of interest because of the long standing femoral swelling before peracute appendicitis led to its removal.

PRESENTATION OF CASE

We present the case of a 71-year-old woman with a swelling of the right medial thigh for over more than 30 years. When the swelling suddenly grew in size and became tender, she was referred to our emergency department. Sonographically as well as clinically a femoral hernia was diagnosed. Intraoperatively, the appendix was found and open appendectomy as well as a hernioplasty was performed.

DISCUSSION

Open appendectomy is an elegant and safe procedure to repair a long standing de Garengeot hernia. Most case reports call for extensive diagnostics such as CT scan etc. We found a sonography of the femoral region to be conclusive.

CONCLUSION

Apart from the inherent risk of sudden incarceration in hernias, De Garengeot hernias can also develop peracute appendicitis years after their formation. This differential diagnosis needs to be taken into consideration in patients presenting with the clinical signs of a femoral hernia.     

De Garengeot Hernia

Background and Objectives:

We report a case of appendicitis presenting in an incarcerated femoral hernia, otherwise known as de Garengeot hernia. This rare hernia usually presents with both diagnostic and therapeutic dilemmas. We wish to underline the usefulness of laparoscopy in both the diagnosis and treatment of de Garengeot hernias.

Methods:

A diagnostic laparoscopy was performed initially. The appendix was seen to disappear into the hernia sac. A laparoscopic appendectomy was then performed prior to open exploration of the groin.

Results:

We were able to obtain a correct diagnosis and perform an appendectomy prior to making a groin incision. Operative findings included an incarcerated, inflamed appendix within a femoral hernia.

Conclusions:

Diagnostic laparoscopy could be a valuable tool in the correct diagnosis and management of unusual presentations of incarcerated groin hernias.     

A combined Richter's and de Garengeot's hernia

INTRODUCTION

de Garengeot''s hernia is very rare. Richter''s hernia is responsible for 10% of acute strangulated hernias.

PRESENTATION OF CASE

A 91-year-old woman with three days of abdominal distention was found on computed tomogram to have an incarcerated femoral hernia. Operation revealed a de Garengeot''s hernia combined with a Richter''s hernia of small bowel. Primary repair was performed along with appendectomy.

DISCUSSION

We discuss these rare hernias, not previously reported in combination, and options for management.

CONCLUSION

Combined de Garengeot''s and Richter''s hernias are rare, represent a significant diagnostic challenge, and should be repaired urgently to prevent ischemic bowel, or limit contamination if ischemia is already present. Use of computed tomography will likely lead to increased pre-operative diagnosis of this rare entity.     

An unusual presentation of perforated appendicitis in epigastric region

INTRODUCTION

Atypical presentations of appendix have been reported including backache, left lower quadrant pain and groin pain from a strangulated femoral hernia containing the appendix. We report a case presenting an epigastric pain that was diagnosed after computed tomography as a perforated appendicitis on intestinal malrotation.

PRESENTATION OF CASE

A 27-year-old man was admitted with a three-day history of epigastric pain. Physical examination revealed tenderness and defense on palpation of epigastric region. There was a left subcostal incision with the history of diaphragmatic hernia repair when the patient was 3 days old. He had an intestinal malrotation with the cecum fixed at the epigastric region and the inflamed appendix extending beside the left lobe of liver.

DISCUSSION

While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality.

CONCLUSION

Atypical presentations of acute appendicitis should be kept in mind in patients with abdominal pain in emergency room especially in patients with previous childhood operation for diaphragmatic hernia.     

Incidental De Garengeot’s hernia: A case report of dual pathology to remember

IntroductionA De Garengeot’s hernia is the very rare dual pathology of a vermiform appendix within a femoral hernia.Presentation of caseWe discuss the rare case of a 62 year old female who presented as an emergency with a strangulated femoral hernia. Within the hernia sac a partly necrotic vermiform appendix was discovered. The patient successfully underwent an appendicectomy and repair of her femoral hernia. The post-operative period was uneventful, with no further issues at follow-up.DiscussionOur case report displays the successful treatment of a De Garengeot's hernia as an emergency admission, with a shorter than average admission time, and no post-operative complications.ConclusionThis is a rare case of dual pathology, of which we believe there are few published cases.     

De Garengeot hernia: an analysis of our experience

Aim The presence of a vermiform appendix in a femoral hernia sac is termed De Garengeot hernia. It may present as a tender and/or erythematous groin swelling and is often misdiagnosed as an incarcerated or strangulated femoral hernia. The purpose of this study is to review the management of De Garengeot hernia at a single institution since 1991. Materials and methods A retrospective analysis of seven consecutive patients operated upon at our institution from 1991 to 2006 with De Garengeot hernia was undertaken. Patients’ demographics, treatment performed and postoperative outcome were analysed. Results There were three men and four women. The median age was 55 years. None of the patients were diagnosed preoperatively. The commonest presenting symptom was painful groin swelling. All patients therefore underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated femoral hernia. Operative findings included four normal appendices, two inflamed appendices and one perforated appendix in the femoral hernial sac. Patients with normal appendix (n = 4) had mesh hernia repair without an appendicectomy. The rest of the patients (n = 3) with abnormal appendix underwent emergency open appendicectomy followed by sutured hernia repair. We had no deaths in this series and one minor wound infection. No recurrent hernia has been detected to date. Conclusion Inflammation of the appendix determines the type of hernia repair and surgical approach. Incidental appendicectomy in the case of a normal appendix is not preferred.     

Meckel's diverticulum with small bowel obstruction presenting as appendicitis in a pediatric patient

Background:

Meckel''s diverticulum is a congenital anomaly resulting from incomplete obliteration of the omphalomesenteric duct. The incidence ranges from 0.3% to 2.5% with most patients being asymptomatic. In some cases, complications involving a Meckel''s diverticulum may mimic other disease processes and obscure the clinical picture.

Methods:

This case presents an 8-year-old male with abdominal pain, nausea, and vomiting and an examination resembling appendicitis.

Results:

A CT scan revealed findings consistent with appendicitis with dilated loops of small bowel. During laparoscopic appendectomy, the appendix appeared unimpressive, and an inflamed Meckel''s diverticulum was found with an adhesive band creating an internal hernia with small bowel obstruction. The diverticulum was resected after the appendix was removed.

Conclusion:

The incidence of an internal hernia with a Meckel''s diverticulum is rare. A diseased Meckel''s diverticulum can be overlooked in many cases, especially in those resembling appendicitis. It is recommended that the small bowel be assessed in all appendectomy cases for a pathological Meckel''s diverticulum.     

Surgical management of a De Garengeot’s hernia using a biologic mesh: A case report and review of literature

IntroductionA De Garengeot hernia is a rare form of femoral hernia, where the appendix is found in the herniated sac. This feature is important to report, as both the diagnosis and the treatment are quite challenging in this particular condition.Presentation of caseWe report the case of a 77-year-old female presenting with a femoral hernia, containing an incarcerated necrotic vermiform appendix (De Garengeot hernia). A laparoscopic appendectomy was performed and the herniated defect was repaired according to Rives technique, using a biological mesh.DiscussionThe De Garengeot hernia is often unexpected and diagnosed intra-operatively. A pre-operative diagnosis is quite difficult, as it often presents clinically as a strangled femoral hernia. In patients without peritoneal signs, a contrast-enhanced Computed Tomography (CT) of the abdomen is useful for the diagnosis. Many surgical techniques have been discussed in literature, but there is no consensus. We show the feasibility and safety of the hernia repair according to Rives technique, through an inguinotomy with a biologic mesh. A laparoscopic approach was used to remove the necrotic appendix.ConclusionThe De Garengeot hernia is an uncommon differential diagnosis for patients presenting with clinical signs of strangled femoral hernia. Although hernia repairs with a synthetic mesh in the presence of appendicitis have been reported, we describe a case of femoral hernia repair using a biologic mesh, in a patient with a De Garengot hernia.     

De Garengeot hernia doubly complicated: A case report

IntroductionA strangulated De Garengeot's hernia with appendicitis is an extremely rare surgical presentation. Therefore, the diagnosis is challenging, and there are no recommendations regarding a specific surgical approach.Presentation of caseWe present the case of a 56-year-old woman with a De Garengeot's hernia doubly complicated: strangulated and with appendicitis in the hernia sac. The diagnosis was made intraoperatively, and it was managed fully through a single inguinal incision. No postoperative complication was presented, and the patient was discharged 48 h after.DiscussionThe clinical presentation of this sub-type of hernia is non-specific. Precise knowledge of the hernia sac content preoperatively is not mandatory, and it should not delay prompt emergency surgery. As long as there are no local signs of complicated appendicitis, a single inguinal incision may be sufficient to perform appendectomy and hernia repair. In the event of complicated appendicitis, an exploratory of the abdominal cavity is mandatory, and hybrid approaches are recommended. For an experienced surgeon, the laparoscopic approach (TAPP), including the treatment of the two pathologies and the exploration of the peritoneal cavity, represents the surgical technique of choice.ConclusionDe Garengeot's strangulated hernia with appendicitis is an exceedingly rare double surgical emergency. When uncomplicated appendicitis, a single inguinal incision is sufficient to treat both appendicitis and abdominal wall defect. Hernia reduction, which young surgeons in the emergency room commonly attempt, should be abolished.     

Appendicitis and Meckel’s diverticulum in a femoral hernia: simultaneous De Garengeot and Littre’s hernia

This report presents the case of a 73-year-old woman who was admitted with sepsis, cachexia and confusion secondary to a strangulated femoral hernia containing both the appendix (De Garengeot hernia) and a Meckel??s diverticulum (Littre??s hernia). She underwent successful operative management and was discharged from hospital on the 10th post-operative day. This is the first report in the literature of a combined De Garengeot and Littre??s hernia within a femoral hernia sac.     

De Garengeot hernia: an uncommon presentation of acute appendicitis

We present a case of a 78-year-old female patient with an uncommon presentation of acute appendicitis. She was found to have a perforated appendicitis which developed in a femoral hernia sack. An appendix present in a femoral hernia is called a De Garengeot Hernia, which is a rare form of femoral hernia. Clinical presentation, diagnosis and management are discussed.     

Laparoscopic Appendectomy Combined with TEP for de Garengeot Hernia: Case Report

Introduction : A de Garengeot hernia is defined as a femoral hernia containing the vermiform appendix. De Garengeot hernia is a rare condition, reported to occur in only 0.8% of all femoral hernias. Acute appendicitis presenting within a femoral hernia is even rarer, occuring in 0.08–0.13% of all cases of acute appendicitis. Case report : We present the case of a 64-year-old woman with the diagnosis of incarcerated groin hernia. An urgent laparoscopy was performed showing the distal part of the appendix passing through a small right-sided femoral hernia. A laparoscopic appendectomy was performed, followed by TEP-procedure for femoral hernia repair. Discussion : To our knowledge, this is the first report of this type of approach for a de Garengeot hernia.     

De Garengeot’s hernia: the importance of early diagnosis and its complications

De Garengeot??s hernia is a rare condition of acute appendicitis in an incarcerated femoral hernia. A 65-year-old woman was admitted to the emergency room with a 3-day history of a painful and non-reducible mass in her right groin. The patient underwent emergency surgery. At exploration, an acute appendicitis in an incarcerated femoral hernia was identified, likely prediagnosed by computed tomography. The postoperative period was uneventful. In De Garengeot??s hernia, early diagnosis is important to reduce the morbidity rate. The surgical approach should be designed according to the condition of the patient, the anatomical position of the appendix vermiformis, and the likelihood of complications.     

Mini-mesh repair for femoral hernia

INTRODUCTION

Femoral hernia consists only 4% of all primary groin hernias. It is described as “the Bête Noire of Hernias” because of its nature and anatomy which is difficult to understand for the surgeons and tendency to recurrence. Although there is some large series of femoral hernia in the literature, few studies prospectively comparing repair techniques especially for this type of hernia has been published. A new technique named mini-mesh repair is described here.

PRESENTATION OF CASE

After hernia sac is dissected completely and sent back into the preperitoneal space, femoral canal is exposed. A round or oval shaped patch is prepared in 1.5–2.5 cm in diameter according to the size of the femoral canal. Mesh is secured to the Cooper''s ligament with 2/0 polypropylene suture. Eight femoral hernias in 8 patients were repaired with this new technique. Patient satisfaction is very good. One seroma and one limited ecchymosis were recorded. No recurrence was observed in a mean follow-up of 22.4 months. No chronic pain was recorded.

DISCUSSION

Many techniques for femoral hernia repair have been described to date with a variety of clinical outcomes. Each technique has its own advantages and disadvantages. Mesh repairs without tension seems to be better choices. When the transversalis fascia is healthy and strong in a patient with femoral hernia a large piece of mesh may be unnecessary. The simple technique described in this paper can be a good alternative. It is totally problem-oriented, and the burden of prosthetic material is very limited.

CONCLUSION

Mini mesh repair may be a good solution for selected patients with femoral hernia.     

Appendicitis in paraumbilical hernia mimicking strangulation: a case report and review of the literature

Purpose

The contents of umbilical or paraumbilical herniae are usually omentum or bowel; rarely, metastatic deposits, appendix epiploicae, or an inflamed vermiform appendix may be found. Unexpected contents cause confusion in the diagnosis, especially when inflamed, and may mimic a strangulated umbilical hernia. Appendicitis in the hernial sac is known in inguinal and femoral herniae; however, only four reported cases of appendicitis within an umbilical hernia could be identified.

Case

A 54-year-old female presented to the emergency with a 2-day history of vomiting, severe pain and irreducibility of a paraumbilical swelling. On examination, we found tachycardia, with a tender, erythematous and irreducible paraumbilical swelling. With a diagnosis of strangulated paraumbilical hernia, the abdomen was explored through an infraumbilical incision. Opening the sac revealed inflammatory fluid, omentum, and an inflamed and edematous appendix. Appendicectomy was performed with anatomical double-breasted repair of the fascial defect. Histopathological examination of the specimen revealed acute appendicitis, periappendicitis and panniculitis in the omentum.

Conclusion

Appendiceal inflammation inside a hernia sac is probably due to extrinsic compression and partial ischemia. Symptoms manifest late, and the final diagnosis is mostly made during the operation. CT scan provides only indirect clues to diagnosis. Appendicectomy and anatomical repair is the appropriate treatment for appendicitis within a paraumbilical hernia.     

Appendiceal diverticulitis in a femoral hernia causing necrotizing fasciitis of the right inguinal region: report of a unique case

De Garengeot’s hernia—a rare finding occurring mostly in women—is defined by the presence of the vermiform appendix within the sac of a femoral hernia. The incidence of appendicitis is rarer still, with less than a 100 cases reported to date. We present a unique case of an 84-year-old male patient with perforated appendiceal diverticulitis within a De Garengeot’s hernia causing abscess and necrotizing infection of the overlying soft tissues.     

Diagnosis and operative management of a perforated de Garengeot hernia

IntroductionA 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 caseA 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.DiscussionFemoral 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.ConclusionFull 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.     

Vanek's tumour mimicking an acute appendicitis

Introduction

Vanek''s tumour or Inflammatory Fibroid Polyp (IFP) are rare, benign localised lesions originating from the sub-mucosa of the gastrointestinal tract (GI) tract.¹ They have been widely reported as occurring within the stomach, Duodenum, Jejunum and Ileum, more rarely (<1%) in the caecum or appendix.

Presentation of case

We present a case of a 28-year-old lady who presented with a 2-day history of right iliac fossa pain, nausea and low-grade fever. Subsequent, ultrasonography (USS) of the abdomen demonstrated an inflamed tubular structure originating from caecum with fluid in the pelvis mimicking an acute appendicitis. Next to normal appendix an inflammatory polypoid mass was identified and on histological examination confirmed to be an IFP (Vanek''s tumour).

Discussion

Right Iliac Fossa (RIF) pain with suspected appendicitis is one of the most common presentations in any acute surgical unit. In young women of childbearing age, the differential diagnosis can be varied and vast. The surgical management of IFP (Vanek''s tumour) in such cases ranges from limited resection and caecectomy to limited right hemicolectomy.

Conclusion

To date, the exact histiogenesis of these tumours remains unclear and requires a high level of intra-operative suspicion. According to our search such presentation is not reported.     

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

IntroductionDe 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 caseAn 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.DiscussionWe 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.ConclusionHere, 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.     

Changing management of suspected appendicitis in the laparoscopic era

INTRODUCTION

The aims of this study were to examine the trends in performance of open and laparoscopic appendicectomy at a district general hospital, and to compare the diagnostic outcomes in the two patient groups.

PATIENTS AND METHODS

Data were collected prospectively from patients undergoing an open or laparoscopic procedure for cted appendicitis in an 8-year period between January 2000 and December 2007.

RESULTS

A total of 1700 patients (873 women, 827 men) with a median age of 24 years underwent surgery for suspected appendicitis in the study period. There were 1357 patients (group A) who underwent an open procedure for presumed appendicitis (610 women and 747 men [F:M ratio, 1:1.2]). There were 343 patients (group B) who underwent laparoscopy with or without laparoscopic appendicectomy (82 men and 261 women [F:M ratio, 1:0.31]). Over the study period, there was an increasing trend towards the performance of laparoscopic procedures for suspected appendicitis, increasing from 4% to 39% of the total per year. In group A, 1172 (86%) patients had appendicular pathology, while the appendix was normal histologi-cally in 178 (13%). Other pathologies were diagnosed intra-operatively in 1%. In group B, 193 patients (56%) had appendicular pathology while in 150 (44%) the appendix was normal. In the subgroup with a normal appendix, 56 patients (37%) had another cause for their symptoms identified.

CONCLUSIONS

Laparoscopic appendicectomy is increasingly being performed. Laparoscopy is often used as a diagnostic tool in general surgical patients, particularly women, with lower abdominal pain. In effect, these patients are undergoing diagnostic laparoscopy, with or without appendicectomy. This has resulted in a lower positive appendicectomy rate, but a higher yield of diagnoses other than appendicitis, in the laparoscopic group. Overall appendicectomy rates, however, have remained unchanged.