Rare presentation of De Garengeot hernia in a 77-year-old woman.

A 77-year-old woman presented with a rare surgical phenomenon known as De Garengeot hernia. This unique presentation occurs due to the presence of a vermiform appendix in a femoral hernia sac. The patient presented with right-sided groin pain and a partially reducible hernia; she was otherwise haemodynamically stable and denied fevers, nausea and vomiting. The diagnosis was confirmed with CT which demonstrated a right-sided femoral hernia containing a perforated tip of the appendix. The patient urgently underwent an open appendectomy and open right femoral hernia repair using the modified McEvedy's incision. © BMJ Publishing Group Limited 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Background

We report a rare case of femoral hernia, De Garengeot hernia which contained appendix in the hernial sac. Femoral hernias, which are less common than inguinal, are more often found in women.1 This is a rare case and usually presents with diagnostic and therapeutic challenges. De Garengeot hernia, and the incidence of appendicitis in this type of hernia are as low as 0.08%–0.13%.2 This hernia must be differentiated from Amyand hernia, which is the presence of the appendix inside an inguinal hernia.3

Case presentation

A 77-year-old woman presented to the surgical admissions unit with right-sided groin pain. She denied fevers, nausea, vomiting, bowel or any urinary symptoms and did not have any recent trauma.

On examination, she had right groin tenderness with a partially reducible femoral hernia, she was haemodynamically stable. Her bloods showed a white cell count of 11.2×109/L and C-reactive protein of 84; the rest of the bloods were within range. Abdominal X-ray showed faecal loading. The impression was a right-sided incarcerated femoral hernia.

Investigations

Ultrasound can reveal the bowel contents in the hernia sac4; however, the patient presented in an acute setting and CT scanning remains the gold standard for diagnosis. She had a CT scan of abdomen and pelvis which showed she had a right femoral hernia containing the appendix (figure 1). The appendix was perforated at its tip within the sac, significant local inflammatory and soft-tissue stranding (figure 2).

Figure 1

CT scan of abdomen-axial.

Figure 2

CT scan of abdomen.

Differential diagnosis

Acute appendicitis should be considered as a differential diagnosis in patients who present with right groin pain. De Garengeot hernias is rare; however, it is important to identify preoperatively which helps planning surgery and obtaining well-informed consent from the patient.

Treatment

Under the diagnosis of incarceration of the right femoral hernia containing perforated appendix, the patient was taken to the emergency theatre and had an open appendectomy and open repair of right femoral hernia. Using modified McEvedy’s incision, contents were reduced containing inflamed and gangrenous appendix and bruised omentum, hernia sac dissected and sac opened. Appendectomy was done and femoral canal obliterated from abdominal side with suture.

Outcome and follow-up

The patient recovered well postoperatively and discharged the same day without any complications. She has been asymptomatic since and was discharged after her 6-week follow-up.

Acute appendicitis should be considered as differential diagnosis in patients who present with right-sided groin pain.

It is important to recognise De Garengeot hernia preoperatively.

CT scanning is an important aid to lead to a diagnosis which can aid in planning surgery.

Obtain a well-informed consent from the patient.