De Garengeot hernia at a country hospital

De Garengeot hernia is defined as a femoral hernia containing the appendix, which can be normal or inflamed. It is a rare condition, comprising of about 1% of all diagnosed hernias. Patients typically present with symptoms of incarceration. There is no consensus on the management of patients with De Garengeot hernia and concurrent appendicitis. To date, less than 100 reports have been published in literature and only a few discussed the use of mesh in an infected femoral field. An 81-year-old female presented to our emergency department with a 3-day history of lower abdominal pain associated with mild nausea. Abdominal examination revealed tenderness in the right femoral region and an incarcerated femoral hernia was suspected. She proceeded to an abdominal computed tomography (CT), which confirmed the suspected diagnosis of a femoral hernia containing appendix without radiological signs of bowel obstruction (Fig. 1). Within an hour, the patient was transferred to the operating theatre and intraoperative inspection revealed a femoral canal containing a sac which had a vermiform appendix as its content, demonstrating a De Garengeot hernia. The fixation involved a high approach with a longitudinal incision extending downwards overlying the hernia sac. The sac was 2 × 3 cm in size with surrounding tissue oedema. The opened sac identified inflamed tip of appendix. Subsequently, the retroperitoneal plane was dissected and peritoneum opened to deliver the appendix under vision. Exploration revealed a healthy base of appendix and an incarcerated tip of appendix herniating through femoral defect of about 0.5 cm in diameter (Fig. 2). There was no perforation. Standard appendicectomy was performed with ligation of base end mesoappendix using absorbable sutures. The extended incision allowed the suture ligation of the sac and a mesh plug was inserted into the femoral ring. The patient made an uneventful recovery and was discharged 2 days later with oral antibiotics for 5 days. There have been no postoperative complications at 8-week follow-up. The first case of appendicitis within a femoral hernia was reported by Rene Jacques Croissant De Garengeot, an 18th century Parisian surgeon who performed the appendicectomy and primary hernia repair in 1731. This hernia is extremely rare ranging from 0.5 to 3.3%, while only 0.13% contain an acutely inflamed appendix. Other rare hernia containing the appendix is the Amyand’s hernia seen in the inguinal region reported in 1% of cases. De Garengeot hernia is often misdiagnosed as incarcerated femoral hernia and the diagnosis of appendicitis is often only made intraoperatively. It is postulated that the signs of appendicitis are not evident clinically because of the local response related to the inflammation within the confined femoral space. A CT scan in our case had demonstrated the appendix within the hernia sac, but only three published cases of CT diagnosed De Garengeot hernia are documented in literature. This further demonstrates the dilemma surrounding this diagnosis, as the surgical treatment for this condition may be more challenging than anticipated based on the patient’s clinical presentation.