de Garengeot hernia: the ultrasound and “>Case Report

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American Journal of Emergency Medicine

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De Garengeot hernia: the ultrasound and computed tomographic findings in an 81-year-old woman

Abstract

The presence of appendix within a femoral hernia is a Rare condition in an incarcerated femoral hernia. It has a characteristic groin mass, and the diagnosis of appendicitis is mainly made intraoperatively. A specific imaging appearance (ultrasonography, computed tomography [CT]) allows accurate prospective diagnosis. The recognition of this rare femoral hernia helps us to choose appropriate therapeutic approach. We report a case of an 81-year-old woman who present with painful and nonreducible groin mass. The ultrasonography and CT character- istic imaging features successfully diagnosed de Garengeot hernia. To our knowledge, this is the first description of a combination of CT and ultrasound in the Preoperative diagnosis.

The appendix in a femoral hernia sac is a rare operative finding. De Garengeot hernia is extremely difficult to be diagnosed preoperatively for the radiologist, and findings will often be nonspecific. However, we report a case with specific radiologic findings using both ultrasound and computed tomography (CT). We reviewed the literature and found that this approach has never been described before.

An 81-year-old woman was admitted with a painful right-sided groin mass, which had been present for 10 days. She denied any fever, nausea, vomiting, change in bowel habit, or recent trauma. Physical examination revealed a small, firm, and tender mass in the right inguinal region measuring 5 x 5 x 3 cm. The mass was nonreducible

Fig. 1. Preoperative ultrasonography of the right groin mass shows an intestinal loop- like structure that is traced back to the base of the cecum (arrowhead). The hernia sac has a tight neck and no fluid contents.

and below the inguinal ligament. Laboratory test results were within normal limits, except for an elevated white cell count (12 030/uL) with 78.1% neutrophils. The patient was evaluated with ultrasonography, which showed bowel and no fluid contents in the hernia sac, and the lumen was dilated to 7 mm (Fig. 1). Because of these findings, the referring clinical team requested CT of the groin and pelvis be performed. This demonstrated a tubular lesion extending into the groin. The appendix was identified as a blind-ending tubular structure, which was traced back to the base of the cecum, herniating into the femoral triangle (Fig. 2). We confirmed that the appendix was the cause of the palpable groin bulge, and a diagnosis of acute appendicitis within a femoral hernia (de Garengeot hernia) was made.

At surgery, a large, inflamed femoral hernial sac, medial to the femoral vein, was identified. The distal appendix was herniated and incarcerated as a result of the narrow hernial gap (Fig. 3). Owing to the normal appendix and narrow hernial mouth, appendectomy could be performed easily, where both the mesoappendix and the appendix were closed using a resorbable clip. The hernia sac was dissected up to the base and ligated. We subsequently performed a herniorrhaphy using the Lichtenstein procedure with a polypropylene mesh due to noninflammation. The wound was closed in layers with absorbable sutures for deep subcutaneous tissues and staples for the skin.

The patient had an uneventful postoperative course, and ultraso- nography showed normal blood flow in the right femoral vein. The histologic examination of the appendix showed acute appendicitis.

Fig. 2. Abdomen CT reveals a blind-ending tubular structure demonstrating the appendix (arrowhead).

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Fig. 3. Intraoperative image of the long appendix through the femoral hernial sac.

The clinical presentation of de Garengeot hernia is a few days of history of a painful groin swelling, suggestive of an incarcerated hernia or a groin abscess. The abscess is usually nonreducible or tender to palpation. The differential diagnosis should include the following: groin hernia, lymph nodes, ectasia of the vena saphena magna, adnexitis, abscesses, or other common groin masses [1,2]. Patients may be feverish, and laboratory values can be atypical.

Preoperative imaging, including ultrasound and CT, has been shown to be an aid to preoperative diagnosis. Abdominal x-ray finding can help in identifying Bowel obstruction, whereas ultrasound has been used to assess bowel content within the hernia sac or the presence of subcutaneous fluid. The characteristics of the acute appendices on ultrasound are noncompressible enlarged appendix (>=6 mm), appendiceal wall thickening compared with other bowel wall, and ultrasound probe-induced tenderness at the area over the appendix [3]. Computed tomography is generally used for improving the diagnosis of appendicitis and has 100% sensitivity and specificity in the diagnosis of acute appendicitis [4]. The prospective CT assessment of the appendix include distended appendix, periappen- diceal fat stranding and infiltration, appendiceal wall enhancement or thickening, cecal apical wall thickening, and presence of extraluminal fluid collection or gas bubbles around the appendix [5]. The rare occurrence of de Garengeot hernias may be attributed to abnormal anatomical position. Some patients have a partially mobile cecum or a longer appendix that cause herniation from the femoral canal. A pelvic appendix, secondary to different degrees of intestinal rotation, has a high risk of entering the hernial sac of the pelvic peritoneum. The inflammation or perforation of the appendix in the hernia sac is usually caused by the narrow hernia neck rather than intraluminal

obstruction of the appendix [2]. computed tomographic imaging of the abdomen can assist in establishing a more accurate diagnosis. In our case, ultrasound and CT showed a typical location of acute appendicitis in a femoral hernia sac, and a diagnosis of de Garengeot hernia was made before operation.

Surgery is the Conventional treatment of femoral hernia. Appen- dectomy via the hernia sac is widely accepted, whereas appendecto- my via traditional McBurney incision can be performed as acute appendicitis occurred [6]. When it is not possible to reach the base of the appendix or when the appendiceal pus is found, the traditional appendectomy is expected. The repair of de Garengeot hernias is also debatable, possibly because of the rarity of this condition. The treatment strategy depends on the condition of the patient and the active contents. The factor contributing to the increased Incidence of infection is the Delay in diagnosis. In our patient, appendectomy and mesh repair surgery were promptly performed. No Wound infection was noted during a follow-up visit.

In conclusion, De Garengeot hernia is a rare condition and often misdiagnosed as an incarcerated or strangulated femoral hernia. Preoperative diagnosis is difficult, and the final diagnosis is most often determined intraoperatively.

Jianpeng Hao, MD Junchao Yao, MD Dawei Guo, MD, PhD Wenyu Sun, MD

Jian Liang, MD, PhD Xiaofeng Jiang, MD, PhD Department of Surgery

the Fourth Affiliated Hospital China Medical University, Shenyang

Liaoning Province, China E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.11.003

References

1. Comman A, Gaetzschmann P, Hanner T, et al. DeGarengeot hernia: transabdominal preperitoneal hernia repair and appendectomy. JSLS 2007;11(4):496-501.
2. Rebai W, Hentati H, Makni A, et al. Appendicitis in strangulated femoral hernia: a case report. Tunis Med 2010;88(3):193-5.
3. Johnson KA, Dewbury KC. Ultrasound imaging of the appendix testis and appendix epididymis. Clin Radiol 1996;51(5):335-7.
4. Allen BC, Kirsch J, Szomstein S. Case 187: De Garengeot hernia. Radiology 2012;265(2):

   640-4.

   Sim JY, Kim HJ, Yeon JW, et al. Added value of ultrasound re-evaluation for patients with equivocal CT findings of acute appendicitis: a preliminary study. Eur Radiol 2013;23(7):1882-90.

5. Erdas E, Sias L, Licheri S, et al. De Garengeot hernia with acute appendicitis. G Chir 2013;34(3):86-9.