Unsuspected femoral hernia in patients with a preoperative diagnosis of recurrent inguinal hernia

Purpose

Small femoral hernias may be difficult to diagnose by physical examination and are sometimes identified unexpectedly by laparoscopy. The aim of this study was to examine the incidence of unsuspected femoral hernia discovered during laparoscopic inguinal hernia repair in two well-defined patient groups.

Methods

Patients undergoing laparoscopic transabdominal preperitoneal inguinal hernia repair from April 2000 until December 2009 (n?=?561) were prospectively registered including data on previous hernia operations and identified type of hernia during surgery. We included patients whose preoperative diagnosis was either bilateral primary inguinal hernia (Primary Group) or recurrent inguinal hernia (Recurrent Group).

Results

Four hundred and sixty-one (82.2?%) patients were included in the study, of whom 211 (45.8?%) was in the Primary Group and 250 (54.2?%) in the Recurrent Group. The incidence of unsuspected femoral hernia in the Recurrent Group [23/250, 9.2?% (95?% CI 5.9–13.5?%)] was significantly higher than in the Primary Group [8/211, 3.8?% (95?% CI 1.7–7.3?%)], p?=?0.02. Furthermore, 38.1?% of women operated on for a recurrent inguinal hernia, presented with an unsuspected femoral hernia at surgery as opposed to 6.6?% of the men, p?=?0.003.

Conclusion

Unsuspected femoral hernias are more prevalent in patients with recurrent hernia than in patients with primary hernia in the inguinal region. Femoral hernias may be unrecognized at the primary inguinal hernia operation, or the previous inguinal hernia operation may facilitate the formation of a femoral hernia. Unsuspected femoral hernias are especially frequent in women with recurrent inguinal hernia. In women with a groin hernia, a femoral hernia should always be excluded by laparoscopy or by open exploration of the preperitoneal space.     

Limited Potential for Prevention of Emergency Surgery for Femoral Hernia

Background

Femoral hernias are frequently operated on as an emergency. Emergency procedures for femoral hernia are associated with an almost tenfold increase in postoperative mortality, while no increase is seen for elective procedures, compared with a background population.

Objective

The aim of this study was to compare whether symptoms from femoral hernias and healthcare contacts prior to surgery differ between patients who have elective and patients who have emergency surgery.

Methods

A total of 1,967 individuals operated on for a femoral hernia over 1997–2006 were sent a questionnaire on symptoms experienced and contact with the healthcare system prior to surgery for their hernia. Answers were matched with data from the Swedish Hernia Register.

Results

A total of 1,441 (73.3 %) patients responded. Awareness of their hernia prior to surgery was denied by 53.3 % (231/433) of those who underwent an emergency procedure. Of the emergency operated patients, 31.3 % (135/432) negated symptoms in the affected groin prior to surgery and 22.2 % (96/432) had neither groin nor other symptoms. Elective patients had a considerably higher contact frequency with their general practitioner, as well as the surgical outpatient department, prior to surgery compared with patients undergoing emergency surgery (p < 0.001).

Conclusions

Patients who have elective and patients who have emergency femoral hernia surgery differ in previous symptoms and healthcare contacts. Patients who need emergency surgery are often unaware of their hernia and frequently completely asymptomatic prior to incarceration. Early diagnosis and expedient surgery is warranted, but the lack of symptoms hinders earlier detection and intervention in most cases.     

Mesh fixation in TAPP laparoscopic hernia repair: introduction of a new method in a prospective randomized trial

Background

Mesh fixation is a critical step in TAPP laparoscopic hernia repair because tackers used for this purpose are associated with possible neuralgia.

Methods

For the present study, 70 patients referred with unilateral inguinal or femoral hernia were divided in two groups for hernia repair. In first group mesh was fixed with titanium tacker. In the second group mesh was fixed with a single suture of Vicryl.

Results

Patients in the Vicryl group experienced less postoperative pain and analgesic consumption. Six month follow-up demonstrated no hernia recurrence either.

Conclusions

According to results, use of Vicryl suture instead of a titanium tacker is beneficial owing to reduced pain, less analgesic consumption, and lower cost.     

Prognostic factors of postoperative morbidity and mortality in strangulated groin hernia

Objective

Strangulated groin hernia is a serious surgical emergency, as it is associated with high morbidity and mortality (2.6–9?%). This retrospective study aimed to find significant prognostic factors of postoperative morbidity and mortality.

Methods

From January 2000 to August 2011, we analyzed all patients who had undergone surgery in emergency for strangulated groin hernia. Forty-nine patients out of 2,917 were operated on strangulated groin hernia in an emergency.

Results

The occurrence of strangulated hernia during this period was 1.7?%. Thirty patients out of 49 had inguinal (61.2?%) and 19 femoral (38.8?%) strangulated hernias. The median age was 68.9?years?±?15.3. Patients with strangulated femoral hernia were significantly older than those with inguinal hernia (P?=?0.03). There was a significant predominance of men in the inguinal hernia group and a female predominance in the femoral hernia group (P?=?0.001). An additional exploration was performed on 12 patients (24.5?%). This exploration was done through a midline laparotomy in 8 patients, a laparoscopy in a single patient and the hernioscopy technique was beneficial in exploring the peritoneal cavity in 3 patients. Intestinal resection was necessary in 10.2?%. In our experience, 50?% of midline laparotomies were performed without any intestinal resection. Fisher’s test identified midline laparotomy as the only prognostic factor of postoperative morbidity.

Conclusion

First intention exploratory laparotomy in strangulated hernia surgery was, in our study, a major cause of postoperative complication.     

Female ‘groin’ hernia: totally extraperitoneal (TEP) endoscopic repair seems the most appropriate treatment modality

Background

About 30% of all female ‘groin’ hernias are femoral hernias, although often only diagnosed during surgery. A Lichtenstein repair though, as preferred treatment modality according to guidelines, would not diagnose and treat femoral hernias. Totally extraperitoneal (TEP) hernia repair, however, offers the advantage of being an appropriate modality for the diagnosis and subsequent treatment of both inguinal and femoral hernias. TEP therefore seems an appealing surgical technique for women with groin hernias.

Methods

This study included all female patients ≥18?years operated for a groin hernia between 2005 and 2009.

Results

A total of 183 groin hernias were repaired in 164 women. TEP was performed in 85% of women; the other 24 women underwent an open anterior (mesh) repair. Peroperatively, femoral hernias were observed in 23% of patients with primary hernias and 35% of patients with recurrent hernias. There were 30 cases (18.3%) of an incorrect preoperative diagnosis. Peroperatively, femoral hernias were observed in 17.3% of women who were diagnosed with an inguinal hernia before surgery. In addition, inguinal hernias were found in 24.0% of women who were diagnosed with a femoral hernia preoperatively. After a follow-up of 25?months, moderate to severe (VAS 4-10) postoperative pain was reported by 8 of 125 patients (6.4%) after TEP and 5 of 23 patients (21.7%) after open hernia repair (P?=?0.03). Five patients had a recurrent hernia, two following TEP (1.4%) and three following open anterior repair (12.5%, P?=?0.02). Two of these three patients presented with a femoral recurrence after a previous repair of an inguinal hernia.

Conclusion

Femoral hernias are common in women with groin hernias, but not always detected preoperatively; this argues for the use of a preperitoneal approach. TEP hernia repair combines the advantage of a peroperative diagnosis and subsequent appropriate treatment with the known good clinical outcomes.     

Sekundäres teleangiektatisches Osteosarkom des linken Femurs

Background

This article presents the unusual case of a 73-year-old male patient who was treated with primary interlocking nailing after a pathological femoral fracture.

Diagnostics

Despite comprehensive diagnostics including several biopsies, a tumor could not be detected. In 2008 when progressive cystic femoral destruction leading to loosening of the nail necessitated a partial femoral prosthesis, an osteosarcoma could first be diagnosed in the resected bone.

Therapy

Advanced progression of the tumor required an extended hip exarticulation. During the current restaging of the now 84-year-old patient no tumor could be detected.

Conclusion

When a malignancy cannot be excluded even by repeated biopsies of radiologically suspicious structures, an adequate tumor staging followed by close monitoring should be carried out. For a clinically silent, long-term course of cystic destruction of a long bone over several years, an age over 60 years and a lack of distant metastases, an atypical osteosarcoma should be considered in the differential diagnosis.     

Single-port laparoscopic percutaneous extraperitoneal closure of femoral hernia in children and adolescents: case series

Background

Femoral hernias are an often unexpected groin pathology during childhood. However, the pediatric surgeon has to be aware to diagnose femoral hernia and to repair this condition. This is the first report on laparoscopic percutaneous extraperitoneal closure of femoral hernia (LPEF) in children and adolescents.

Methods

Over a 6-year period in a bi-institutional clinical study, we retrospectively identified six children and one young adult who underwent LPEF repair.

Results

Femoral hernia was laparoscopically confirmed in seven patients. Ages at surgery were 3, 5, 7, 7, 8, 8.5, and 18 years, respectively. In the first case, we combined laparoscopic diagnosis with open repair. In the consecutive six cases, hernias were repaired minimally invasively with the percutaneous extraperitoneal technique described below. During a follow-up between 6 years and 6 months, no recurrence was observed.

Surgical technique

For LPEF, we percutaneously placed a peritoneal U-shape suture with integrated transfixation of the hernia sac, closed with an epifascial knot. We performed LPEF using two graspers. The peritoneum was percutaneously punctured with a venous cannula through which the suture was inserted. One grasper was inserted through the working channel of the laparoscope to invert the hernia sac into the abdominal cavity. A mini-grasping forceps inserted through the cannula retrieved the thread and completed LPEF.

Conclusion

We demonstrate that single-port laparoscopic percutaneous extraperitoneal closure of femoral hernia is successful and quick in children and in adolescents.

     

Risk factors related with unfavorable outcomes in groin hernia repairs

Purpose

Hernia repairs are a common surgical procedure, and are associated with a significant cost. Despite the acceptance of the advantages of early elective hernia repairs, the incidence of emergency admissions with complicated presentations remains high, and the natural history of an untreated hernia is not obvious. This study aimed to define risk factors related with unfavorable outcomes in groin hernia repairs.

Methods

We analyzed the records of 685 elective or emergency repairs of groin hernias between December 2005 and June 2009. Patient age ranged from 17 to 85 years, with 240 (35%) of patients being older than 60 years of age. Indirect inguinal hernias were the most common hernia type in both sexes of patients. Coexisting cardiopulmonary problems were noted in 294 male and 33 female patients. American Society of Anaesthesiologists (ASA) grades 3 and 4 were encountered in 61 (9%) patients. Data were analyzed by chi-square test.

Results

Significantly high incarceration and strangulation rates were found in females and femoral hernia type. The overall morbidity rate was 7%, major complications 3%. No mortality was observed in the series and postoperative complications were significantly more common in patients with high ASA score and severe coexisting cardiopulmonary problems. Advanced age, delayed admission, femoral type hernia and female sex were also linked with unfavorable outcomes.

Conclusions

The risk of complicated presentation and unfavorable outcome in patients with groin hernia is significant in the presence of factors such as advanced age, femoral hernia, female sex, delayed admission, severe coexisting cardiopulmonary problems and high ASA score. Although it is difficult to estimate the natural history of untreated hernia, hernia repairs of patients with the above-mentioned risk factors should be timely and elective.     

The inheritance of groin hernia: a systematic review

Background

Groin hernia has been proposed to be hereditary; however, a clear hereditary pattern has not been established yet. The purpose of this review was to analyze studies evaluating family history and inheritance patterns and to investigate the possible heredity of groin hernias.

Methods

A literature search in the MEDLINE and Embase databases was performed with the following search terms: genetics, heredity, multifactorial inheritance, inheritance patterns, sibling relations, family relations, and abdominal hernia. Only English human clinical or register-based studies describing the inheritance of groin hernias, family history of groin hernias, or familial accumulation of groin hernias were included.

Results

Eleven studies evaluating 37,166 persons were included. The overall findings were that a family history of inguinal hernia was a significant risk factor for the development of a primary hernia. A family history of inguinal hernia showed a tendency toward increased hernia recurrence rate and significantly earlier recurrence. The included studies did not agree on the possible inheritance patterns differing between polygenic inheritance, autosomal dominant inheritance, and multifactorial inheritance. Furthermore, the studies did not agree on the degree of penetrance.

Conclusion

The literature on the inheritance of groin hernias indicates that groin hernia is most likely an inherited disease; however, neither the extent of familial accumulation nor a clear inheritance pattern has yet been found. In order to establish whether groin hernias are accumulated in certain families and to what extent, large register studies based on hernia repair data or clinical examinations are needed. Groin hernia repair (inguinal and femoral hernia) is among the most commonly performed gastrointestinal surgical procedures [1]. Emergency groin hernia surgery is associated with increased mortality, increased patient-related morbidity, and increased hospital stay compared with elective groin hernia procedures [2, 3]. Identifying patients at high risk of developing groin hernia would therefore provide the possibility of timely elective surgical intervention, thus reducing the rate of emergency procedures. It could also potentially make way for individualized surgical methods in the future.     

Use of Cold-Stored Vein Allografts for Venous Reconstruction During Pancreaticoduodenectomy

Introduction

Venous resections and reconstructions of portal vein and/or superior mesenteric vein in course of pancreaticoduodenectomy are becoming a common practice and many surgical options have been described, from simple tangential resection and venorrhaphy to large segmental resections followed by interposition grafting. The aim of this study was to report the first experience of using fresh cadaveric vein allografts for venous reconstruction during pancreaticoduodenectomy focusing on technical feasibility and postoperative outcomes.

Methods

From January 2001 to October 2012, out of 151 patients undergoing pancreaticoduodenectomy for pancreatic head tumor, 22 (14.5 %) received a vascular resection of the mesentericoportal axis. In five of these patients, vascular reconstruction was accomplished by using cold-stored venous allografts of iliac and femoral veins from donor cadaver. Patients’ data, surgical techniques, and clinical outcomes were analyzed.

Results

Five patients undergoing pancreaticoduodenectomy were selected to receive a vascular reconstruction using a fresh venous allograft for patch closure in three cases, conduit interposition in one case and a Y-shaped graft in the last case. No graft thrombosis or stenosis occurred postoperatively and at long-term follow-up. Mortality rate was zero.

Conclusion

The use of fresh vein allografts is a feasible and effective technique for venous reconstruction during pancreaticoduodenectomy. However, prospective surveys including large cohorts of patients are necessary to confirm these results.     

Direct inguinal hernias and anterior surgical approach are risk factors for female inguinal hernia recurrences

Purpose

The purpose of this study was to establish the risk of recurrence after direct and indirect inguinal hernia operation in a large-scale female population and to establish the relationship between the type of hernia at the primary and recurrent procedure.

Methods

Using data from the Danish Hernia Database (DHDB), a cohort was generated: all females operated on electively for a primary inguinal hernia by either Lichtenstein’s technique or laparoscopy from 1998 to 2012. Within this prospectively collected cohort, the hernia type at the primary procedure (direct inguinal hernia (DIH), indirect inguinal hernia (IIH), combination hernia), the hernia type at the recurrent procedure (DIH, IIH, combination hernia, femoral hernia), anesthesia type, and time from primary procedure to reoperation were registered.

Results

A total of 5,893 females with primary elective inguinal hernia operation on in the study period (61 % IIH, 37 % DIH, 2 % combined hernias) were included with a median follow-up time of 72 months (range 0 to 169). A total of 305 operations for suspected recurrences were registered (61 % inguinal recurrences, 38 % femoral recurrences, 1 % no hernias), which corresponded to an overall reoperation rate of 5.2 %. All femoral recurrences occurred after a previous open anterior operation. The crude reoperation rate after primary DIH operation was 11.0 %, 3.0 % after primary IIH operation and 0.007 % after combined hernia operation (p?<?0.001). The multivariate adjusted analysis found that DIH at primary operation was a substantial risk factor for recurrence with a hazard ratio of 3.1 (CI 95 % 2.4–3.9) compared with IIH at primary operation (p?<?0.001), and that laparoscopic operation gave a lower risk of recurrence with a hazard ratio of 0.57 (CI 95 % 0.43–0.75) compared with Lichtenstein’s technique (p?<?0.001). The risk of femoral recurrence was correlated to operation for DIH with a hazard ratio of 2.4 (CI 95 % 1.7–3.5) compared with operation for IIH.

Conclusion

In a female nationwide prospectively gathered cohort, we found that operation for a DIH resulted in a higher risk of reoperation than operation for an IIH. We found that femoral hernia recurrences exclusively existed after anterior open primary operation.     

Two-stage laparoscopic treatment for strangulated inguinal,femoral and obturator hernias: totally extraperitoneal repair followed by intestinal resection assisted by intraperitoneal laparoscopic exploration

Purpose

Total extraperitoneal preperitoneal (TEP) repair is widely used for inguinal, femoral, or obturator hernia treatment. However, mesh repair is not often used for strangulated hernia treatment if intestinal resection is required because of the risk of postoperative mesh infection. Complete mesh repair is required for hernia treatment to prevent postoperative recurrence, particularly in patients with femoral or obturator hernia.

Cases

We treated four patients with inguinocrural and obturator hernias (a 72-year-old male with a right indirect inguinal hernia; an 83-year-old female with a right obturator hernia; and 86- and 82-year-old females with femoral hernias) via a two-stage laparoscopic surgery. All patients were diagnosed with intestinal obstruction due to strangulated hernia. First, the incarcerated small intestine was released and then laparoscopically resected. Further, 8–24 days after the first surgery, bilateral TEP repairs were performed in all patients; the postoperative course was uneventful in all patients, and they were discharged 5–10 days after TEP repair. At present, no hernia recurrence has been reported in any patient.

Conclusion

The two-stage laparoscopic treatment is safe for treatment of strangulated inguinal, femoral, and obturator hernias, and complete mesh repair via the TEP method can be performed in elderly patients to minimize the occurrence of mesh infection.

     

Contemporary hernia smartphone applications (apps)

Aims

Smartphone technology and downloadable applications (apps) have created an unprecedented opportunity for access to medical information and healthcare-related tools by clinicians and their patients. Here, we review the current smartphone apps in relation to hernias, one of the most common operations worldwide. This article presents an overview of apps relating to hernias and discusses content, the presence of medical professional involvement and commercial interests.

Methods

The most widely used smartphone app online stores (Google Play, Apple, Nokia, Blackberry, Samsung and Windows) were searched for the following hernia-related terms: hernia, inguinal, femoral, umbilical, incisional and totally extraperitoneal. Those with no reference to hernia or hernia surgery were excluded.

Results

26 smartphone apps were identified. Only 9 (35 %) had named medical professional involvement in their design/content and only 10 (38 %) were reviewed by consumers. Commercial interests/links were evident in 96 % of the apps. One app used a validated mathematical algorithm to help counsel patients about post-operative pain.

Conclusions and opportunities

There were a relatively small number of apps related to hernias in view of the worldwide frequency of hernia repair. This search identified many opportunities for the development of informative and validated evidence-based patient apps which can be recommended to patients by physicians. Greater regulation, transparency of commercial interests and involvement of medical professionals in the content and peer-review of healthcare-related apps is required.     

Venenaneurysma – Therapieentscheidung durch sonographische Diagnostik der Hämodynamik

Background and aim

In the literature, the diagnosis and treatment of venous aneurysms is reported based only on case reports or small case series. Information to differentiate ectasia from aneurysms, and clear recommendations for surgical indications in asymptomatic, incidentally detected aneurysms based on imaging are rarely found.

Methods

Morphological characterization with sonography and flow analysis with treatment-relevant contrast agent and color duplex ultrasound were used. Concerning the indication for surgery, our own series of patients with venous aneurysm with follow-up and a review of the literature from 1990–2012, focusing on morphological imaging criteria, were included in the evaluation.

Results

Color duplex ultrasonography allows representation of flow conditions and at high spatial resolution, a valid statement about the character of the aneurysm and the risk of thromboembolic complications can be made. Based on the analysis of the ultrasound results, a treatment strategy (flow analysis) is presented (prevalence in the subgroup 0.7 %) for surgical resection of symptomatic and asymptomatic saccular aneurysms from our own series of 8 saccular and 13 fusiform popliteal venous aneurysms. For fusiform aneurysms, a conservative approach (follow-up) is justified.

Discussion and conclusion

Based on morphological characterization of aneurysms using sonography and blood flow analysis using color duplex and contrast agent-derived ultrasound, criteria for risk of thromboembolic complications and the indication for surgery can be described.     

Open preperitoneal mesh repair of inguinal hernias using a mesh with nitinol memory frame

Purpose

To prospectively evaluate the use of a continuous Nitinol containing memory frame patch during a TIPP-technique in the open repair of inguinal and femoral hernias.

Methods

Over a 3-year period all consecutive adult patients that needed treatment for an inguinal or femoral hernia were treated by the TIPP repair using the Rebound Shield mesh. Intra-operatively the type and size of the hernia were evaluated according to the EHS classification, as well as the size of the mesh used. Baseline characteristics for all patients were evaluated considering age, gender, BMI and American society of Anesthesiologists score. Standard X-ray was performed to evaluate mesh position. All patients were evaluated for post-operative pain using the visual analogue scale (VAS 0–10 scale).

Results

In total 289 groin hernias were operated using a nitinol containing patch in 235 patients. The mean operating time was 38 min for unilateral hernias and 59 min for bilateral hernias. The median follow-up is 21.2 months (14–33 months) during which three patients died, unrelated to the groin hernia repair. At the time of re-evaluation 12 patients (5.0 %) complained of chronic pain, with a VAS score higher than 3 after 3 months (range 3–10). Two of these patients already had severe pain pre-operatively. A total of 3 recurrences (2.9 %) were noted with strong correlation with X-ray findings.

Conclusion

A nitinol memory frame containing mesh is a valuable tool to achieve complete deployment of a large pore mesh in a TIPP repair for inguinal hernias with acceptable morbidity and a low recurrence rate.     

Laparoscopic Transabdominal Preperitoneal Hernioplasty for Reduction En Masse of an Incarcerated Inguinal Hernia: A Case Report

Introduction

Reduction en masse is a rare complication of an incarcerated inguinal hernia. Its occurrence should be suspected when intestinal obstruction persists despite a seemingly successful manual reduction or hernioplasty.

Case Report

We report our experience in the management of a reduction en masse of a direct inguinal hernia. The diagnosis was established by computed tomography of the abdomen. The reduction en masse, as well as an accompanying indirect hernia, was successfully managed with laparoscopic transabdominal preperitoneal hernioplasty.

Conclusion

The safety, effectiveness, and minimal invasiveness conferred by the laparoscopic approach justified its application under such conditions.     

Transabdominal Preperitoneal Repair for Obturator Hernia

Background

A laparoscopic surgical approach for obturator hernia (OH) repair is uncommon. The aim of the present study was to assess the effectiveness of laparoscopic transabdominal preperitoneal (TAPP) repair for OH.

Methods

From 2001 to May 2010, 659 patients with inguinal hernia underwent TAPP repair at in our institutes. Among these, the eight patients with OH were the subjects of this study.

Results

Three of the eight patients were diagnosed as having occult OH, and the other five were diagnosed preoperatively, by ultrasonography and/or computed tomography, as having strangulated OH. Bilateral OH was found in five patients (63%), and combined groin hernias, either unilaterally or bilaterally, were observed in seven patients (88%), all of whom had femoral hernia. Of the five patients with bowel obstruction at presentation, four were determined not to require resection after assessment of the intestinal viability by laparoscopy. There was one case of conversion to a two-stage hernia repair performed to avoid mesh contamination: addition of mini-laparotomy, followed by extraction of the gangrenous intestine for resection and anastomosis with simple peritoneal closure of the hernia defect in the first stage, and a Kugel hernia repair in the second stage. There was no incidence of postoperative morbidity, mortality, or recurrence.

Conclusions

Because TAPP allows assessment of not only the entire groin area bilaterally but also simultaneous assessment of the viability of the incarcerated intestine with a minimum abdominal wall defect, we believe that it is an adequate approach to the treatment of both occult and acutely incarcerated OH. Two-stage hernia repair is technically feasible in patients requiring resection of the incarcerated intestine.     

Central diaphragmatic hernia in an adult: a rare presentation

Introduction

An adult presentation of congenital diaphragmatic hernia is very rare. Here, we present a rare case report of left-sided central diaphragmatic hernia in an adult. Laparoscopic repair of the hernia was performed with mesh placement.

Case summary

A 19-year-old adult man was presented with pain in abdomen and occasional vomiting. X-ray and CT scan thorax was suggestive of diaphragmatic hernia with herniation of stomach. Laparoscopic repair were performed with mesh placement.

Discussion

Central diaphragmatic hernia is rarely seen in adults. Only one such case is reported so far. Successful repair was performed with laparoscopy. Patient recovered well without any postoperative complications.     

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.