Abstract

Appendix within a femoral hernia is a rare and often an incidental finding at surgery; and finding appendicitis in a femoral hernia is even rarer. We are discussing the case of a 77-year-old female with a femoral hernia containing an inflamed appendix diagnosed on MRI.

Introduction

An inguinal hernia sac containing an appendix is known to many surgeons; however, appendix within a femoral hernia is a rare finding. The Parisian surgeon Rene Jacques Croissant de Garengeot was the first to describe an appendix within a femoral hernia in the year 1731.¹ While a femoral hernia containing an appendix is rare, the presence of appendicitis in a femoral hernia is even rarer.¹ Appendicitis in a femoral hernia occurs commonly as a result of external pressure from the hernia neck rather than intramural obstruction of the appendix. Clinical signs, including erythema, induration, and overlying subcutaneous air, are known to be associated with a perforated appendix in a femoral hernia. However, most cases of appendicitis in femoral hernias are diagnosed at the time of surgery.²

Case report

A 77-year-old female with no significant past surgical history was referred by her primary care physician for evaluation of a right inguinal hernia. The patient noted a small groin “bulge” two weeks before and denied any fever, nausea or vomiting. On examination, there was a 2-cm cord-like mass below the inguinal ligament, but the area was not erythematous or tender to palpation. Because of the unusual presentation and physical examination that suggested a soft tissue mass, the decision was made to perform abdominopelvic magnetic resonance. A subsequent computed tomography scan was also performed at the suggestion of the radiologist, based on the MRI findings. 

The MRI showed a femoral hernia containing an inflamed appendix. The patient was admitted to the hospital, started on antibiotics and scheduled for laparoscopic appendectomy. During laparoscopy, it was evident that the appendix was sliding into the femoral hernia defect. The appendix was reduced and resected. The abdominal wall defect was then plugged with a biologic mesh and covered with peritoneum. The patient tolerated the procedure well and was discharged home the following day.

Discussion

The appendix in a femoral hernia (de Garengeot hernia) is a rare and usually incidental finding at surgery, occurring in 0.5% to 5% of all femoral hernias. It was first described by Rene Jacques Croissant de Garengeot in 1731, way before Claudius Amyand performed the first reported appendectomy through an inguinal hernia sac.^1-3

Femoral hernias account for nearly 4% of all groin hernias. These are more commonly seen in women who are postmenopausal. Femoral hernias occur when the contents of the peritoneum enter the femoral canal. These types of hernias have the highest rate of strangulation due to the firm margins of the femoral ring.²

Several reports have been published about the surgical procedure for hernias and appendix. The introduction of laparoscopy was a significant milestone in the development of appendectomies.⁴ Laparoscopic hernia treatment has become an integral part of surgical routine. Total extra peritoneal hernia repair (TEP) and transperitoneal preperitoneal hernia repair (TAPP) are commonly done in the present times.⁴ The treatment for De Garengeot hernia involves prompt appendectomy and hernioplasty. Laparoscopy seems to be a good technique to determine the condition of the hernia. Additionally, for hernia repair, delayed repair or suturing repair is often recommended rather than synthetic mesh in anticipation of infection. However, recent studies suggest that in the absence of any signs of abscess formation or perforation, repair by prosthetic mesh is possible without infection or recurrence.³

References

1. Akopian G, Alexander M. De Garengeot hernia: appendicitis within a femoral hernia. Am Surg. 2005;71:526-527.
2. Filatov J, Ilibitzki A, Davidovitch S, Soudack M. Appendicitis Within a Femoral Hernia. Sonographic Appearance. Journal of Ultrasound in Medicine 2006;25(9):1233-35.
3. Ebisawa K, Yamazaki S, Kimura Y, et al. Acute Appendicitis in an Incarcerated Femoral Hernia: A Case of De Garengeot Hernia. Case Rep Gastroenterol. 2009 Sep-Dec; 3(3): 313–317.
4. Comman A, Gaetzschmann P, Hanner T, Behrend M. DeGarengeot hernia: transabdominal preperitoneal hernia repair and appendectomy. JSLS. 2007;11:496-501