De Garengeot Hernia, Déjà Vu : A Unique Report

BACKGROUND The presence of a vermiform appendix incarcerated within a femoral hernia is known as a de Garengeot hernia (DGH). These hernias are extremely rare entities with less than 100 documented cases uploaded to PubMed’s database. Most develop sporadically with no prior history of femoral herniation. We present the unique case of a 59-year-old female with a retrospectively suspected two-year history of a femoral hernia, who developed an acutely incarcerated and strangulated DGH requiring prompt surgical management. CASE INFORMATION A 59-year-old female presented to the Emergency Department complaining of a three-day history of a painful right groin lump. She was clinically diagnosed with a right inguinal hernia two years prior. On presentation, she stated that she coughed and felt her hernia ‘pop out’ but was unable to reduce it. A round, firm mass was appreciated caudal to her inguinal ligament and was tender, irreducible and non-fluctuant. Overlying erythema and skin changes were identified. She had a low-grade fever (99°F), with a WBC of 13.73 x109/L and lipase of 162. CT imaging revealed a right groin hernia containing the appendix with significant inflammatory changes and suspicions for strangulation and superimposed primary acute appendicitis. The radiologist interpreted the groin hernia as inguinal (Amyand hernia), while the surgeon interpreted it as femoral (DGH). Intraoperatively, a femoral hernia was identified containing murky fluid surrounding an inflamed and necrotic appendix. An appendectomy followed by a natural tissue hernia repair (McVay) was performed. Histopathologic examination of the excised specimen revealed acute suppurative appendicitis with severe peri-appendicitis. CONCLUSIONS De Garengeot hernias are very rare entities and account for less than 1% of all femoral hernias. Though effective in other conditions, imaging plays a limited role in diagnosis and treatment of DGH due to its low sensitivity and specificity. These factors may result in varying interpretations of a single scan as seen by the radiologist and surgeon in this case. There are various surgical management options available. However, in this case an appendectomy followed by primary repair was performed as the strangulated appendix posed a high risk for post-operative complications. When evaluating a patient with a groin hernia and controversial CT result, it is important to use one’s clinical suspicion to help guide the surgical approach and management options.