Case Report : Rare presentation of De Garengeot Hernia

The presentation of an incarcerated appendix within a femoral hernia accounts for 0.5-3.3% of all femoral hernias. It is rarely apparent diagnostically prior to surgery. A 48-year-old female had a delayed presentation with a 3-day history of an irreducible right inguinal swelling. Imaging failed to elucidate an incarcerated appendix, which was found at operation. The patient made a full recovery. The rarity and presentation of this condition is discussed. On literature review it typically is not suspected at operation due to its rarity and the difficulty of interpreting it on examination and imaging.


Introduction
The presentation of femoral hernia with an incarcerated appendix accounts for 0.5-3.3% of all femoral hernias 1 ; very few cases have been described 2 .The condition is named after Rene De Garengeot, a French surgeon who first described it in 1731 3 .The condition may be described as the femoral counterpart of the more widely described Amyand hernia, involving appendicitis within the inguinal hernia sac 1 .

Patient information
A 48-year-old woman presented to Dalby Hospital (a small rural facility) with a 3-day history of an irreducible right inguinal swelling, which came on while cycling a mountain bike.A timeline of care is given in Table 1.She had initially not presented as she suspected a muscle strain but presented when the pain became worse.She reported 2-3 previous occurrences of a lump in the same location many years ago, which had self-resolved.Her prior medical history was notable: 13 previous pregnancies with 10 natural deliveries and 3 terminations, LLETZ procedure for cervical cancer, no previous abdominal surgeries.She was an active smoker with a 25 pack-year history.She took no regular medications.

Clinical examination
The patient was initially examined by a rural general practitioner who was concerned for incarcerated hernia.He discussed the case with the surgical registrar at Toowoomba hospital and arranged for interhospital transfer.On transfer that evening to Toowoomba Hospital (Toowoomba, Queensland, Australia), a regional facility with 240 beds, the swelling was red and inflamed.The patient was haemodynamically stable, afebrile and was moving her bowels.A right sided, painful swelling could be palpated in the right inguinal region.The registrar examining the patient was suspicious for an incarcerated femoral hernia.In the absence of obstructive symptoms it was suspected that this was incarcerated fat only.

Investigations
In order to exclude the more serious diagnosis of incarcerated bowel with the hernia and to confirm the diagnosis of femoral hernia, an initial ultrasound was ordered by the treating surgical registrar after discussion with the consultant of the night.In addition a full blood count and electrolytes with liver function tests was ordered.The blood tests were all in the normal range.Meanwhile the ultrasound was reported as an inguinal hernia with suspicion of incarcerated small bowel.The discrepancy of this radiological finding with the clinical findings caused further discusion between the radiology sonographer, consultant and the surgical team; the diagnosis of the type of hernia and its contents mandated the urgency of theatre, approaches and timing.As a result, a CT was ordered to further investigate the anatomy in this case.
The initial findings of the CT scan were suggestive of an inflamed inguinal hernia with predominant fat contents and probable bowel involvement.There was no radiographic evidence of a small or large bowel obstruction.As this patient's bowels were still moving, it was felt that this was most likely caused by incarcerated, strangulated fat, rather than bowel.
The patient was taken to theatre.Because of the above findings, an incision was made over the inguinal ligament, expecting to find an incarcerated inguinal hernia.Instead, on dissection, a femoral hernia was encountered.The sack was opened and necrotic mucosal content was encountered.It was suspected that this was necrotic bowel requiring resection, so the decision was made a low midline laparotomy to ensure safe resection.On opening, a necrotic appendix was found to be incarcerated in the femoral hernia.
The appendix being reduced, the mesoappendix was clamped, divided and ligated, and the appendix was removed with a purse string suture used to bury residual mucosa.The femoral hernia was repaired primarily with nylon to the conjoin tendon after excision of the sac.A Blake drain was placed and laparotomy wounds were closed with looped Novafil sutures.The patient was placed on Ceftriaxone, 1 g daily and metronidazole 500 mg BD.
The patient recovered swiftly, and was discharged on day 3 following surgery (Table 1).Her antibiotics were ceased after 24 hours and she was treated with simple analgesia only as required.She was subsequently seen in the outpatients' clinic at 2 weeks after surgery, and had made a full recovery.

Discussion
This case was notable for its rarity and the clinical and radiological difficulty anticipating the incarceration of the appendix in the femoral canal.This might have mandated a different approach on surgery than might have been undertaken.Accurate diagnosis of the condition would allow for appropriate choosing of incision, or a laparoscopic approach.On review of the literature, this is typical of this rare condition, however.Excepting one Japanese study 4 , the diagnosis was typically made serendipi- tously at surgery.This is not unique, to De Garengeot's hernia; there can often be confusion between femoral hernia and inguinal hernias, particularly upon clinical examination.Littre's hernia containing Meckel's diverticulum and a Richter's hernia are often also diagnosed on the table rather than in the radiologist's suite.
The rarity of this condition contributes to this.De Garengeot's is an exceedingly rare condition, accounting for 0.5-3.3% of femoral hernias 1 , which are rare in and of themselves, accounting for only 3-5% of all presentations of hernia.This can make clinical and radiological suspicion all the more challenging.
The suspicion of a De Garengeot's hernia earlier on imaging would have dictated either a laparoscopic approach, which may have also been useful to confirm the diagnosis, or a midline mini-laparotomy.Laparoscopic repair has been described as feasible for treatment of this condition; however, its rarity and difficulty of diagnosis prior to operation would make prospective comparison extremely difficult.
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