ePoster #8 | Clinical Science | General Surgery

J Kim, C Castro, G Coleman, G Ng

Presenter: Jisoo Kim, MD, Texas Tech University HSC – El Paso

Introduction/Objective: When the appendix is found within a femoral hernia, it is called a De Garengeot hernia. Appendicitis has been associated and found within these hernias, are usually found as an emergent finding at presentation, and have an incidence of 0.08-0.13%. Despite being first described almost two centuries ago, there are less than 500 cases reported in literature. Studies have suggested that previous inguinal herniorrhaphy may increase the risk of femoral hernias up to 15 times higher compared to spontaneous incidence. We present a case of De Garengeot hernia, with appendicitis, in a patient who had a previous right sided inguinal herniorrhaphy.

Case Presentation: We present a case of a 56-year-old Hispanic male complaining of 5 days of sharp right groin pain and bulge. Eight years ago, he underwent an open right inguinal hernia repair with mesh. Laboratory studies showed no leukocytosis. Physical exam revealed a well healed right groin scar, a visible bulge that was non-reducible, and mild erythema overlaying the skin. A Computed Tomography (CT) scan was performed revealing a right femoral hernia with a 1.5 cm neck containing a dilated appendix, with mural thickening, mucosa enhancement, and fat stranding within the hernia sac. The patient was taken to the operating room and underwent an open femoral herniorrhaphy and appendectomy with right inguinal and midline lower laparotomy incisions. Intraperitoneal evaluation revealed an intact inguinal hernia repair with plug mesh, without recurrence. The 1 cm femoral hernia was repaired with a free formed biologic mesh plug and sutured in place. The patient had an uneventful recovery and was discharged home post-operative day 2. He was seen in follow up 2 weeks post operative and doing well.

Discussion: Available literature supports the rarity of the De Garengeot hernia. Presentation of this hernia is still variable, especially since peritoneal and systemic symptoms may be limited due to confinement within the femoral canal without extension into the peritoneal cavity when appendicitis is concurrent. The pathophysiology of De Garengeot hernia include an enlarged cecum, a cecum positioned low in the pelvis, or an abnormal intestinal rotation pushing the appendix into the femoral canal. Since the femoral ring is narrow, the risk of incarceration increases the chance of resultant appendicitis. A standardized surgical approach to De Garengeot hernia is still to be determined. The current treatment of choice is appendectomy with herniorrhaphy, either via open, or open combined with laparoscopic approach. Primary tissue repair, or repair with mesh (biologic versus synthetic) must also be considered based on degree of contamination.

Conclusion: De Garengeot hernia is unique, challenging to diagnose, and requires emergent surgical intervention. Though the operative approach is not standardized, it is reasonable to base intervention on a case by case basis, surgeon preference, and comfort with procedures performed for treatment of this hernia.

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