De Garengeot’s Hernia: Report of a Rare Surgical Emergency and Review of the Literature

This is a report of a case who was admitted and operated on for a strangulated femoral hernia. The hernia sac contained a gangrenous appendix, which was excised and the hernia was repaired with sutures without complication. De Garengeot's hernia, although very rare, should be included in the differential diagnosis of cases with strangulated hernia and should receive the optimal treatment.

found and a lump emerging from the subcutaneous tissue below the inguinal ligament was identified ( Figure 1B). After identification of the sac, the adjacent tissues were dissected, and the sac was opened. Unexpectedly the sac contained a vermiform appendix ( Figure 1C) emerging from the femoral canal along with a small quantity of clear fluid (negative for bacteria). The appendix was incarcerated within the sac, inflamed and its blind end exhibited early signs of necrosis ( Figure 1D). The appendix was resected and the femoral ring was approximated with sutures without use of a mesh. The patient's postoperative course was uneventful; he tolerated oral intake and his bowel movements returned to normal within 24 h. He was discharged on the 3rd postoperative day. Histology of the resected appendix showed inflammatory changes within the appendix consistent with appendicitis and peri-appendicitis.

DisCussion
Femoral hernia cases constitute an uncommon cause of groin lumps, which account for 3-5% of all abdominal hernias. The appendix is reported to be present inside the hernia sac in approximately 1% of the cases (3), and the incidence of appendicitis is even rarer, occurring in 0.08-0.13% of all patients. The clinical preoperative diagnosis of de Garengeot's hernia can be challenging and often encountered randomly during surgery especially in cases where the patients are urgently led to surgery without preoperative imaging examination. Due to the narrow and rigid femoral neck of femoral canal, this type of hernia is much more likely to become incarcerated and strangulated. Sequentially strangulation can result in acute appendicitis or even worse in perforation and abscess formation. The treatment of choice for this type of hernia is emergency surgery. Appendectomy and primary hernia repair should be performed simultaneously.
Several surgical approaches for the treatment of de Garengeot's hernia have been described; open (inguinal or midline incision) or laparoscopic appendectomy plus primary repair of the femoral hernia with/without mesh (Lichtenstein or TAPP technique) (3,5,8,17,20,22,26,27,30). Most surgical strategies began with an inguinal or an oblique incision over the irreducible lump (26 of the patients). Six patients had a laparotomy with a lower midline incision, because of a high possibility of abscess or perforation (9,11,12,14,16,19). Only in 2 published cases the surgical team chose the laparoscopic approach for both appendectomy and hernia repair (one TAPP procedure and one case primary repair). (8,22) There is currently no formal consensus regarding the optimal approach (open or laparoscopic) for the treatment of femoral hernia. Although it would be preferable not to use a mesh in a patient with well-documented inflammation, successful repair with mesh has been reported. (3,5,8,17,20,22,26,27,30) Therefore, the decision on whether to use a mesh or not depends on the surgeon's preference in each individual case.
Herein we described a case of a 56 year old male patient, who was admitted to our center and finally underwent emergency surgery for an irreducible lump in his right groin. Intraoperatively, a de Garengeot's hernia was identified. Pathological examination demonstrated acute appendicitis with transmural necrosis and peri-appendicitis. De Garengeot's hernia should be in included in the physician's differential diagnosis in patients with pain and swelling in their right groin. To that end, despite the urgency of this surgical case, surgical teams must perform imaging studies (preferably computerized tomography), which will demonstrate the exact kind of hernia (inguinal or femoral) and the content of the sac (omentum, bowel, appendix etc), with the aim to tailor the optimal surgical approach for each case.

inFoRmeD Consent
Written informed consent was obtained from the patient for the publication of this case report.

autHoR ContRiButions
EM is the chief surgeon of this case and the main author of this case report, APa helped him in this operation and, with VD, contributed in the collection and interpretation of data. NZ is a pediatric Surgeon in our Department and contributed in analyzing the patient's clinical reports and obtained informed consent of the patient. NK and NM are chief resident and postdocroral fellow, respectively, in our Department and helped in reference collection and selection, and the writing of the paper. APr and TK are surgeons from another Hospital who helped in the collection of literature references and review analysis. AM is the Professor and Chairman in our Department and supervised the writing of this report.