Preoperative Diagnosis and Surgical Management of De Garengeot Hernia

Abstract

Background

An 81-year-old woman with no significant past surgical history presented to the emergency department with acute pain in a pre-existing right groin bulge. Notably, the bulge had been asymptomatic for several months prior to this presentation.

Summary

An 81-year-old woman presented with acute pain in a preexisting right groin bulge. Physical examination did not support a diagnosis of acute appendicitis. However, a CT scan revealed a De Garengeot hernia, a rare condition where the appendix protrudes through the femoral canal. Given the uncommon nature of this hernia, there are no standardized treatment guidelines. The patient underwent a successful open repair of the femoral hernia with reduction of the appendix.

Conclusion

This case exemplifies the successful preoperative identification of a De Garengeot hernia using CT imaging. Notably, surgical management achieved hernia repair without requiring abdominal exploration or appendectomy, suggesting a potentially minimally invasive approach for select cases.

Key Words

hernia; De Garengeot hernia; femoral hernia; appendix

Case Description

An 81-year-old woman with no significant past surgical history presented to the emergency department with acute right lower quadrant (RLQ) abdominal pain superimposed on a preexisting, asymptomatic right groin bulge. She had noticed the bulge for several months but sought medical attention only after experiencing a sudden “pop” followed by nausea and pain. Although she reported loose stools for weeks, she denied any recent fevers, chills, vomiting, or changes in appetite. Physical examination revealed RLQ tenderness and a partially reducible bulge in the anterior thigh. Vital signs were within normal limits, and laboratory tests (CBC, BMP, lactate) were unremarkable. A CT scan confirmed the presence of an RLQ hernia containing the appendix.

An oblique incision was made to access the hernia sac. The sac was dissected from surrounding tissues and freed down to the fascia. Upon opening the sac, a healthy and viable appendix was visualized, devoid of any signs of acute inflammation or malignancy. Given the absence of classic appendicitis symptoms and the normal appendix appearance, appendectomy was deemed unnecessary. The hernia sac was then closed in a running fashion using 3-0 Vicryl suture. Subsequently, the McVay technique was employed to address the femoral defect. This involved suturing the transversalis fascia to Cooper’s ligament with interrupted 3-0 PDS sutures, ensuring meticulous hemostasis and avoiding inadvertent femoral vein injury.

Figure 1. Coronal Abdominal CT Scan Demonstrating De Garengeot Hernia. Published with Permission

Discussion

In contrast to an Amyand hernia, which is the protrusion of the vermiform appendix through the inguinal canal, De Garengeot hernia is a rare form of femoral hernia in which the appendix protrudes through the femoral canal.^1-5 These types of hernias are rare within the spectrum of femoral hernias. They are four times more likely to occur in postmenopausal women compared to men. Risk factors include smoking, chronic cough, pregnancy related complications and constipation.⁶ A De Garengeot hernia is seen within only 0.13% to 1% of all cases of acute appendicitis and 0.5% to 3.3% of all femoral hernia presentations.^1,9,10 Patients clinically present with an irreducible groin lump. They can have fevers with symptoms of bowel obstruction. Peritonitis is often rare due to the presence of the appendix within the femoral canal—in this situation, perforations would be contained with no spillage to the peritoneal cavity.⁶

Reports of successful diagnosis prior to surgery are seldom described. In a 1974 study evaluating 59 cases of De Garengeot hernia, only one author stated to having made the diagnosis prior to surgery.⁹ Evolution of CT imaging has improved preoperative diagnosis. However, there are cases as early as 2013 that still fail to diagnose this type of hernia prior to operation.^11-12 A high level of awareness should be maintained in cases of presentation of femoral hernia with concerns for incarceration and nonvisualization of the appendix. There is no consensus on treatment for these types of hernias, although many techniques have been described. The hernia sac should be violated to assess for appendicitis. Treatment of acute gangrenous appendicitis was described with appendectomy through the hernia sac and simultaneous hernia repair with synthetic mesh.¹⁰ Another modality for management of an inflamed incarcerated appendix was performed through a transabdominal preperitoneal (TAPP) approach using propylene mesh after laparoscopic appendectomy due to failure to establish preoperative diagnosis.¹³ If appendicitis is encountered, an appendectomy through the hernia sac should be attempted prior to either abdominal, laparoscopic, or open approaches.

Conclusion

De Garengeot hernia, due to its rarity, presents challenges in establishing a standardized treatment approach. Both open and laparoscopic techniques can be used for femoral defect closure. Traditionally, open repairs utilize the McVay technique, suturing the conjoined tendon to Cooper’s ligament. Conversely, laparoscopic repairs typically involve mesh closure of the femoral canal, although primary repair with sutures and a peritoneal flap remains an option.

Importantly, appendectomy is not routinely recommended for De Garengeot hernias unless preoperative suspicion of appendicitis exists. In fact, to minimize potential mesh-related complications, avoiding appendectomy during open repairs is generally advisable. Our case demonstrates a successful treatment strategy for De Garengeot hernia involving manual reduction of the vermiform appendix and a primary open hernia repair without appendectomy or laparoscopic access.

Lessons Learned

Unlike traditional femoral hernia repair, De Garengeot hernias may not always necessitate abdominal exploration or appendectomy. This minimally invasive approach can be a viable option depending on the specific clinical scenario.Patients clinical picture on presentation is often consistent with an incarcerated or strangulated femoral hernia and there should be a high clinical suspicion and consideration of De Garengeot hernia as one of the differential diagnoses of right lower quadrant pain. Neither abdominal entry nor appendectomy are required to successfully treat De Garengeot hernias.

Authors

Toledo S^a; Hamdan M^a; Keita PM^b; Weinberger J^c

Author Affiliations

1. Department of General Surgery, Lehigh Valley Hospital, Allentown, PA 18103
2. Department of General Surgery, Carle Foundation Hospital, Urbana, IL 61801
3. Department of Trauma/Acute Care Surgery, Lehigh Valley Hospital, Allentown, PA 18103

Corresponding Author

Jason Weinberger, DO
Division of Trauma/Acute Care Surgery
1200 Cedar Crest Boulevard
Allentown, PA 18103
Email: jason.weinberger@lvhn.org

Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding/Support

The authors have no relevant financial relationships or in-kind support to disclose.

Received: March 3, 2022
Revision received: May 1, 2022
Accepted: May 22, 2022

References

1. Thomas B, Thomas M, McVay B, Chivate J. De Garengeot hernia. JSLS. 2009;13(3):455-457.
2. Nguyen ET, Komenaka IK. Strangulated femoral hernia containing a perforated appendix. Can J Surg. 2004 Feb;47(1):68-9. PMID: 14997930; PMCID: PMC3211803.
3. Fukukura Y, Chang SD. Acute appendicitis within a femoral hernia: multidetector CT findings. Abdom Imaging. 2005 Sep-Oct;30(5):620-2. doi: 10.1007/s00261-004-0283-3. Epub 2005 Mar 30. PMID: 15803225.
4. Akopian G, Alexander M. De Garengeot hernia: appendicitis within a femoral hernia. Am Surg. 2005 Jun;71(6):526-7. PMID: 16044937.
5. Granvall SA. De Garengeot hernia: a unique surgical finding. JAAPA. 2014 May;27(5):39-41. doi: 10.1097/01.JAA.0000443968.31234.63. PMID: 24758977.
6. Bidarmaghz B, Tee CL. A case of De Garengeot hernia and literature review. BMJ Case Rep. 2017 Sep 7;2017:bcr2017220926. doi: 10.1136/bcr-2017-220926. PMID: 28882935; PMCID: PMC5589054.
7. Sorelli PG, El-Masry NS, Garrett WV. Open femoral hernia repair: one skin incision for all. Sorelli PG, El-Masry NS, Garrett WV. Open femoral hernia repair: one skin incision for all. World J Emerg Surg. 2009 Nov 30;4:44. doi: 10.1186/1749-7922-4-44. PMID: 19948016; PMCID: PMC2789711.
8. Klipfel A, Venkatasamy A, Nicolai C, Roedlich MN, Veillon F, Brigand C, Rohr S, Romain B. Surgical management of a De Garengeot's hernia using a biologic mesh: A case report and review of literature. Int J Surg Case Rep. 2017;39:273-275. doi: 10.1016/j.ijscr.2017.08.012. Epub 2017 Aug 18. PMID: 28881337; PMCID: PMC5587892.
9. Voitk AJ, Mcfarlane JK, Estrada RL. Ruptured appendicitis in femoral hernias: report of two cases and review of the literature. Ann Surg. 1974;179(1):24-6.
10. Kiyoko E, Shintaro Y, Yuki K, Mitsuhiko K, Katsumi K, Seigo Y, et al. Acute Appendicitis in an Incarcerated Femoral Hernia: A Case of De Garengeot Hernia. Case Rep Gastroenterol. 2009; 3(3):313-317.
11. Powell HD. Gangrenous appendix in femoral hernial sac. Lancet. 1954 Dec 11;267(6850):1211-2. doi: 10.1016/s0140-6736(54)92266-7. PMID: 13213165.
12. V. Ardeleanu, S. Chicos, D. Tutunaru, C. Georgescu. A Rare Case of Acute Abdomen: Garengeot Hernia. Chirurgia (Bucur). 2013 Nov-Dec;108(6):896-9. PMID: 24331333.
13. Comman A, Gaetschmann P, Hanner T, Behrend M. DeGarengeot hernia: transabdominal preperitoneal hernia repair and appendectomy. JSLS 2007;11:496–501.