|Year : 2016 | Volume
| Issue : 1 | Page : 23-25
De Garengeot's hernia: A case description and surgical approach
Daniela Guevara1, Eric Edwards2, Gustavo Fernandez Ranvier2
1 Department of Surgery, Icahn School of Medicine, Mount Sinai Hospital, Mount Sinai, New York, USA
2 Department of Surgery, Division of Metabolic, Endocrine and Minimally Invasive Surgery, Icahn School of Medicine, Mount Sinai Hospital, Mount Sinai, New York, USA
|Date of Web Publication||25-Oct-2016|
Gustavo Fernandez Ranvier
Department of Surgery, Division of Metabolic, Endocrine and Minimally Invasive Surgery, Icahn School of Medicine, Mount Sinai Hospital, 5 East 98th Street, Box 1259, New York, NY 10029
Source of Support: None, Conflict of Interest: None
Femoral hernias account for 3% of all hernias and can frequently present with incarceration of omentum, preperitoneal fat, small bowel and colon, and more rarely a Meckel's diverticulum or appendix. De Garengeot's hernia (GH) is a rare type of femoral hernia representing 1% of all femoral hernias and contains the vermiform appendix. The purpose of this report is to present a case of GH with discussion of the clinical findings along with description and details of the surgical technique applied for its repair.
Keywords: De Garengeot′s hernia; femoral hernia; laparoscopic De Garengeot′s hernia repair; vermiform appendix
|How to cite this article:|
Guevara D, Edwards E, Ranvier GF. De Garengeot's hernia: A case description and surgical approach. Saudi J Laparosc 2016;1:23-5
| Introduction|| |
Femoral hernias comprise a herniation of the peritoneal sac into the femoral canal and/or femoral triangle and account for approximately 3% of all hernias.  Femoral hernias are prone to incarceration and may contain omentum, preperitoneal fat, small bowel, colon, Meckel's diverticulum or appendix. , De Garengeot's hernia (GH) is a rare type of femoral hernia (1% of all femoral hernias) which contains the vermiform appendix and was first described by De Garengeot in 1731.  The purpose of this report is to present a case of GH with discussion of the findings and surgical management.
| Case Report|| |
An 83-year-old male with a history of an open bilateral inguinal hernia repair 15 years ago presented with a 3 days history of localized pain in the right groin. On physical examination, there was a tender, nonreducible bulge in the right groin with erythema in the overlying skin. Computed tomography (CT) scan of the abdomen and pelvis [Figure 1] was performed and showed the right groin hernia with an acutely inflamed, incarcerated appendix in the hernial sac with surrounding inflammatory changes. The patient was admitted to the hospital and then taken to the operative room where a laparoscopic transabdominal preperitoneal right inguinal hernia repair and appendectomy was performed.
The patient was placed on the operating table in the supine position, and the procedure was performed under general anesthesia. A Foley catheter was placed. Pneumoperitoneum was established at 15 mmHg utilizing a Veress needle and a 5 mm optical trocar was placed in the umbilicus under direct vision. An 11 mm optical trocar was placed in the left lateral abdominal wall and an additional 5 mm trocar was placed in the right lateral abdominal wall. [Figure 2] and [Figure 3] summarize the step-by-step key parts of the procedure. In Trendelenburg position, the abdominal exploration revealed that the appendix was incarcerated in a groin hernia. A peritoneal flap was raised from the level of the anterior superior iliac spine laterally to the border of the umbilical ligament medially. Inspection of the cord structures did not reveal any evidence of an indirect inguinal hernia and upon exploration of the space of retzius there was no direct inguinal hernia noted. The appendix was indeed incarcerated in the femoral space. To facilitate its reduction, the medial aspect of the ligament in the femoral canal was divided. After its reduction, the appendix appeared hyperemic but it did not appear that the patient had primary appendicitis. However, there was some murky fluid in the hernial sac, which was suctioned. An appendectomy was then performed in the usual fashion using an endoscopic mechanical stapler. The cord structures were preserved and intact. Given the fact that there was a potentially contaminated area in the femoral canal, it was elected not to put a prosthetic mesh for repair. Instead, a 10 cm × 15 cm Vicryl mesh was placed into the preperitoneal space. The mesh was positioned to provide coverage of the direct, indirect, femoral, and obturator hernia spaces. The mesh was secured medially to the Cooper's ligament, and superiorly and laterally to the abdominal wall with a titanium tacking device. The peritoneal pressure was turned down at 10 mmHg and the peritoneal flap was then reapproximated using a running 2-0 absorbable suture. The trocars were then removed, the pneumoperitoneum deflated, and the wounds closed.
The patient recovered well from surgery and was discharged home with good condition on postoperative day #2. At 2-month follow-up, the patient was recovering well with no evidence of hernia recurrence.
| Discussion|| |
Femoral hernias are more common in women (1:13).  The higher prevalence among women has been attributed to the body changes during pregnancy and the post menopause period as a result of a larger femoral canal.  It is known that multiparous women have a higher risk of developing GH although men possess a higher risk than nulliparous women.  Other risk factors include increased intra-abdominal pressure, smoking, advanced age and collagen defects and it occurs most frequently in the right side. 
The presence of appendix in the hernial sac is depend on the anatomical variation of its position, size, the embryological intestinal rotation, a more mobile cecum or perhaps a larger cecum that occupies a large space in the pelvic cavity.  The hypothesis for the development of GH is the size and stiffness of the femoral ring, where the appendix is subject to external compression and possibly incarceration and strangulation of the hernia. 
The vermiform appendix is not the only structure that can be found in a femoral hernia. Previous reports have documented the presence of small intestine, colon, and even stomach.  The main differential diagnosis of an incarcerated femoral hernia should include an inguinal hernia, an Amyand hernia (inguinal hernia with the vermiform appendix as the content), a lipoma or other neoplasms of the groin, lymphadenopathy, and more rarely a great saphenous vein ectasia, retroperitoneal abscess, and adnexitis. ,
The most common presentation of GH is an irreducible and painful groin bulge associated with local inflammatory signs as was seen in our case. The finding of an acutely inflamed appendix is rare, occurring in only 0.08%-0.013% of all patients.  It is not clear whether the acute appendicitis found in some cases is due to incarceration or the natural process involved in the development of acute appendicitis. Patients with GH with associated acute appendicitis usually do not present with peritonitis and the cardinal features of a systemic infection.  The signs and symptoms of acute peritonitis are prevented by the fact that the neck of the hernial sac is so narrow and rigid that it effectively prevents the spreading through the abdominal cavity. 
Femoral hernias can be diagnosed clinically, but the presence of a structure inside the sac is very difficult to assess. The diagnosis of GH can be suspected on CT or magnetic resonance imaging of the pelvis when requested; otherwise, the diagnosis will typically be made during surgery. ,, The GH can be associated with complications such as appendicular ischemia, necrosis, perforation, peritonitis or local inflammation, abscess formation, necrotizing fasciitis, and intestinal loop obstruction. 
GH is generally suitable for laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP). However, the procedure may be limited by the expansion of the infection originating from the appendix. Compared with open repair and the totally extraperitoneal repair procedures, the TAPP method has the benefit of visualizing the intrabdominal contents and the ability to treat the problem through the laparoscopic approach. In those cases with widespread infection, the option to switch to an open procedure followed by an open inguinal surgery repair in one or two stages should be considered. 
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]