De Garengeot Hernia, an acute appendicitis in the right femoral hernia canal, and successful management with transabdominal closure and appendectomy: a case Report

Incarceration of the appendix within a femoral hernia is a rare condition of abdominal wall hernia about 0.1 to 0.5% in reported femoral hernia [1]. We report a case of a 56-year-old female whose appendix was trapped in the right femoral canal. There are few reports in the literature on entrapment of the appendix within a femoral hernia. The management of this condition includes antibiotics, drainage appendectomy, hernioplasty and mesh repair.

Formation of Biologic Plug and Patch Mesh for Use in Perforated Femoral Hernia

Incarcerated inguinal hernias with contamination frequently lead to an open inguinal hernia primary repair. If no contamination is present, a tension-free repair with mesh is a good option. In this case, we encountered an incarcerated femoral hernia with perforation of the small bowel. We will describe and demonstrate via video how to incorporate a tension-free repair with mesh in a contaminated field with formation of a plug and patch made from biologic mesh.

Predictive factors of bowel necrosis in patients with incarcerated femoral hernia

PURPOSE

Intestinal necrosis is a frequent complication in patients with incarcerated femoral hernias (IFH). Knowing the low incidence of IFH, few series with large samples studied predictive factors of intestinal necrosis. The main objectives of our study were to determine the predictive preoperative factors of intestinal necrosis in patients with IFH and to compare its morbidity with that related to incarcerate inguinal hernias (IIH).

METHODS

We conducted a retrospective observational cohort study in which we included patients with incarcerated groin hernias (IGH). This is a single-center study between January 2004 and December 2021. Patients were divided into two groups: group A (admitted for IFH) and group B (admitted for IIH). Intestinal necrosis was confirmed intraoperatively.

RESULTS

383 patients with IGH were included in the study: 91 patients had IFH (23.76%) and 282 patients had IIH (76.24%). In patients with IFH, the median age was 67 years. We had 60 females (66%) and 31 males (34%). Bowel ischemia was present in 29 patients (32%). Bowel necrosis was present in 14 patients (16%). We identified three independent variables predicting bowel necrosis in patients with IFH: Duration from symptoms to surgery, NLR (Neutrophil to Lymphocyte ratio), and urea. Bowel ischemia and bowel necrosis were significantly higher in patients with IFH compared to those with IIH.

CONCLUSIONS

In summary, we found that duration from symptoms to surgery, NLR, and urea were significantly predictive of intestinal necrosis in patients with IFH.

De Garengeot's hernia: A masked abdominal perforation

INTRODUCTION

de Garengeot's hernias occur when an inflamed appendix is encased within a femoral sac. This is a relatively rare type of femoral hernia. As a result, there are currently no guidelines for the management of these hernias.

CASE

We present a 90-year-old woman with a de Garengeot's hernia complicated with strangulation and perforation. The diagnosis was made intraoperatively, and it was managed with hernia repair and an appendicectomy. There were no postoperative complications.

DISCUSSION

The presentation of de Garengeot's hernias is non-specific. Enclosure of the bowel content within the hernia sac may mask systemic systems of disease. Rarely, septic signs or symptoms are identified on presentation. It is typically diagnosed intraoperatively, thus prompt emergency surgery should not be delayed by clinicians awaiting precise knowledge of the sac content via imaging. Prompt surgery with a single McEvedy incision enables treatment for both the appendicitis and abdominal wall defect, an appendectomy and hernia repair, respectively. In patients that present with an irreducible femoral hernia and biochemistry suggestive of an acute inflammatory process, there should be a high clinical suspicion for de Garengeot's hernia due to the risk of perforation being masked by an anatomical encasement around the perforated bowel content.

De Garengeot's hernia patients entirely treated laparoscopically: a safe and feasible alternative-a systematic review

PURPOSE

Less than 450 cases of femoral hernias containing the vermiform appendix have been published since De Garengeot's first description. A laparoscopic treatment option opened 15 years ago seems reliable and safe. A literature review of all the patients who have benefited from this new therapeutic alternative is presented.

METHODS

A systematic review using the German Society of Surgery's recommendations was performed for De Garengeot's hernias totally treated laparoscopically. Keywords searched included "De Garengeot hernia" OR "femoral hernia appendix" OR "crural hernia appendix."

RESULTS

Only 29 out of 225 De Garengeot hernia's manuscripts were identified describing patients entirely treated laparoscopically: 25 patients by a transabdominal preperitoneal hernia repair (TAPP) and 4 patients by a total extraperitoneal (TEP) procedure; 85.1% were females. The mean age was 71 years. Twenty-two patients had pre-operative imaging tests, sonography (2), computed tomography (14), or both (6). Nevertheless, only 56% had a preoperative diagnosis. Twenty-one cases required urgent treatment, while programmed surgery was possible in 7 instances. An appendix-sparing procedure could be done in 16% of the TAPPs. No postoperative complications occurred. The median hospital stay was 2.5 days.

CONCLUSIONS

The best surgical approach for a De Garengeot's hernia is not defined, and many critical questions remain unanswered. A better understanding of the diagnosis and treatment of this peculiar hernia will supply guidelines for clinicians who may encounter it hereafter. A fully laparoscopic approach seems perfectly safe and feasible for this entity, and it could be considered the first-line alternative if enough expertise is available.

De Garengeot Hernia: A Total Extraperitoneal Approach to a Femoral Hernia Repair

Introduction:

A de Garengeot’s hernia is a femoral hernia containing the appendix and accounts for approximately 0.8% of all femoral hernias.

Presentation of the Case:

This paper describes a case of an 84-year-old female who presented with abdominal pain, believed to have an incarcerated femoral hernia. Patient underwent a hernia repair and was found to have a femoral hernia involving the appendix, a de Garengeot’s hernia. The femoral hernia was repaired using a total extraperitoneal (TEP) approach.

Discussion:

There are a variety of reported ways to repair a de Garengeot hernia. In this case, we discuss the successful use of the TEP approach to repairing a de Garengeot hernia.

Conclusion:

Although rare, a de Garengeot hernia must remain on the differential when evaluating a patient for an incarcerated femoral hernia. A TEP approach provides the surgeon the ability to perform a variety of hernia repairs, regardless of what is encountered during the operation.

[Strangulation of the appendix in an inguinal hernia sac in children]

OBJECTIVE

To study the features of the clinic and treatment of children with infringement of the appendix in inguinal hernias in children.

MATERIAL AND METHODS

We observed 12 children with the localization of the appendix in the right inguinal hernia. Four of them had an infringement of the appendix: two with inguinal hernia, two with sliding inguinal and femoral hernias. To verify the diagnosis, we used clinical and laboratory examinations of children with restrained inguinal hernia, ultrasound and Doppler examination of the groin and scrotum, X-ray, morphological examination of surgical materials. 4 clinical observations are presented.

RESULTS AND DISCUSSION

Difficulties in diagnosing acute appendicitis in case of infringement of the appendix in inguinal hernias in children are associated with an atypical clinical picture, which proceeds under the mask of OZO. Testicular infarction was found in 2 children with strangulated inguinal hernia and necrosis of the appendix. Combined surgery with abdominal and herniatomical access for sliding restrained hernias in 2 children made it possible to perform a radical operation and avoid severe postoperative complications.

CONCLUSIONS

1. Infringement of the appendix in inguinal hernias in children is rare. 2. The clinical picture of the restrained appendix in the hernial sac proceeds under the mask of OZJ. 3. Operative access in the groin area when the appendix is infringed in the hernial sac is the operation of choice. 4. In case of infringement of the appendix with sliding hernias (inguinal and femoral), the operation of choice can be abdominal and herniatomical approaches.

Obstructed right Duari hernia

The caecum and appendix are uncommon contents of femoral hernia (Duari hernia). Diagnosis is usually intraoperative. We report a rare case of obstructed right femoral hernia in a 65-year-old woman. She was admitted into the accident and emergency department because of sudden irreducibility of a previously reducible right groin swelling of 5 years duration. She had obstructive symptoms with an irreducible right groin mass clinically diagnosed as obstructed right femoral hernia. A combination of infra-inguinal transverse incision and a lower midline laparotomy incision was used. The intraoperative findings included the herniation of the caecum and appendix into the right femoral canal. Patient had an uneventful recovery. Duari hernia is uncommon. A high index of suspicion and an experienced surgeon, who can handle uncommon findings should be involved in the management of obstructed femoral hernias.

Strangulated richter's hernia with caecum necrosis. Case report

AIM

Describe a rare case of Richter's hernia with caecum incarceration into a right femoral hernia and provide a narrative literature review about its surgical management.

MATERIAL AND METHODS

A 46-year-old woman presented to the Emergency Department and to our surgical unit with a two-days history of worsening abdominal pain in the right lower quadrant without nausea or vomiting, associated with an irreducible lump. Computed tomography of the abdomen described a right inguinal hernia containing small bowel with perivisceral fluid in it without signs of small bowel occlusion nor perforation.

RESULTS

A Richter 's femoral hernia with necrotic caecum wall was found but the appendix was not involved. Through a mini-laparotomy, tangential caecal resection and appendectomy were performed. The femoral defect was repaired with a polypropylene mesh-plug placed in the pre-peritoneal space. Postoperative period was uneventful and the patient was discharged on the fifth post-operative day.

DISCUSSION

Femoral hernias account for only 2-4% of all groin hernias and occur through a small fascial defect in the femoral canal. Due to its narrowness, it leads to a high risk of incarceration and strangulation thus explaining the increased mortality in the emergency setting (up to 10 fold compared with the elective repair). In some cases, symptoms are no specific and uncommon findings have been reported. Surgical exploration is mandatory in the presence of signs of bowel strangulation or perforation and different approaches (either open or laparoscopically) have been described in literature.

CONCLUSIONS

Caecum wall necrosis secondary to an incarcerated Richter's femoral hernia is a rare but dangerous event. Surgical approach is selected on surgeon's expertise. The use of prosthetic mesh is always recommended.

KEY WORDS

Bowel necrosis, Emergency surgery, Hernia repair, Richter's hernia.

A Novel Approach to Managing a Strangulated De Garengeot's Hernia

De Garengeot's hernia, the presence of an incarcerated vermiform appendix within a femoral hernia, is a rare general surgery emergency that predominantly affects elderly female patients. Due to its rarity, there is significant variation in surgical technique; however, most case reports favor an open approach. Here we present a case of a De Garengeot's hernia with a unique hybrid open and laparoscopic repair, utilizing the hernia defect as a port site. We will also review the relevant literature.

Laparoscopic treatment of De Garengeot hernia with Progrip

BACKGROUND

Many eponyms have been used to classify some rare conditions of incarceration of a hernia at the level of the groin and femoral canal. The incarceration of the appendix at the level of the groin canal was first described by Claudius Amyand, while the incarceration of the appendix inside the femoral canal is a condition known as De Garengeot hernia. The incidence of such an event is very low and surgical treatment is usually performed via inguinal approach.

CASE PRESENTATION

We describe the case of a 63-year-old woman who presented upon arrival at the Emergency Room a sore tumefaction in the femoral region with skin erythema. The patient had never undergone surgery for groin or femoral hernias. After performing ultrasound reporting the presence of an incarcerated intestinal loop, the patient underwent surgery. Laparoscopic exploration highlighted the presence of a De Garengeot hernia. After exploration, it was decided to continue the laparoscopic operation: at first, the hernia sac was reduced, then a self-gripping mesh was put in place. Finally, after the closure of the peritoneum, the operation was completed by performing a laparoscopic appendectomy. The patient was discharged from hospital three days from surgery with an antibiotic therapy for further two days after discharge. After three months, upon clinical examination, no recurrences of hernia were evident.

CONCLUSIONS

We describe a rare case of De Garengeot hernia treated laparoscopically. The treatment of such a condition is not standardized because of the few cases described. The laparoscopic approach should always be considered to perform at least an exploration of the abdominal cavity and evaluate the contents of the hernia sac. Laparoscopic hernia treatment should be carried out by experienced surgeons who are familiar with the technique and apply it routinely.

KEY WORDS

Appendicitis, De Garengeot, Hernia, Laparoscopy.

A rare case of incarcerated femoral hernia containing small bowel and appendix

An 81-year-old woman was admitted under the acute medical team with a significant acute kidney injury secondary to presumed gastroenteritis, following a 5-day history of diarrhoea and vomiting. She continued to deteriorate despite resuscitative efforts. Subsequently, a non-contrast CT scan revealed likely small bowel obstruction second to a Richter's hernia in the inguinal canal. At diagnostic laparoscopy, both small bowel and appendix were identified to be incarcerated within the right femoral canal. The patient recovered uneventfully and was safely discharged several days following a laparoscopic appendicectomy and right femoral hernia repair.

Coexisting incarcerated femoral and obturator hernia: a case report

BACKGROUND

Obturator hernia is a rare condition associated with a high morbidity and mortality. It is an uncommon cause of bowel obstruction most commonly described in elderly females with comorbidity. Surgical intervention is often delayed as a result of subtle presenting signs. Coexisting ipsilateral femoral hernia is an even rarer condition represented by non-exhaustive series in the literature.

CASE PRESENTATION

We report a case of a healthy 36 years old lady, nulliparous, with abdominal pain and swelling in the right groin. Preoperative CT showed only a right groin hernia, that was found to be femoral at operative intervention. She recovered and was discharged from hospital but represented with further symptoms of obstruction 9 days later. Diagnostic laparoscopy demonstrated a ipsilateral obturator hernia with associated bowel infarct. The bowel was resected and the defect was repaired.

DISCUSSION AND CONCLUSIONS

Obturator hernia presents subtly with medial thigh pain and no lump. They are notorious for difficulty to diagnosis. We describe the first case of coexisting ipsilateral femoral and obturator hernias in a young nulliparous woman with bowel obstruction. Appropriate intraoperative exploration should always be considered.

Acute appendicitis complicating De Garengeot's hernia treated with combined laparoscopic-open technique: a case series and literature review

An acute appendicitis in the context of a De Garengeot's hernia is a very rare event and represents a hard challenge for surgeons. As only few cases have been reported in literature, there is no consensus about its optimal surgical strategy of treatment. Here we present two consecutive cases of female patients presenting an uncommon acute appendicitis in a femoral hernia treated with a combined laparoscopic/open technique.

KEY WORDS

Acute appendicitis, De Garengeot's hernia, Laparoscopy.

De Garengeot's Hernia; Acute Appendicitis In An Incarcerated Femoral Hernia

Acute appendicitis and incarcerated femoral hernia belong to relatively well known surgical diseases with regard to diagnostic workup and treatment. de Garengeot's hernia is an entity involving concurrent occurrence of both the above mentioned problems. This paper presents history of a 58-year old female patient who was diagnosed with this extremely rare syndrome. She presented to the Emergency Room of a hospital in Żyrardów due to painful mass in the right groin region, persisting for approximately 24 hours. De Garengeot's hernia, through combination of two separate surgical entities, is associated with diagnostic difficulties and the therapeutic process occasionally requires unconventional decisions to be taken to improve prognosis.

Low-grade serous primary peritoneal carcinoma incidentally found in a hernia sac

Very rarely, a primary peritoneal serous carcinoma can be observed in a hernia sac. We herein describe a low-grade serous primary peritoneal carcinoma incidentally found in a postmenopausal woman following examination of the femoral hernia repair sac. Our case is significant for its unusual presentation. The lesion initially appeared as a 0.3-cm tumor that disseminated in the peritoneum, persisted, and progressed for 75 months. The absence of ovarian disease indicated a primary peritoneal origin. Tumor cells were immunohistochemically positive for PAX8, claudin-4, and VE1, excluding the possibility of being of mesothelial origin. Recognition that a low-grade serous primary peritoneal carcinoma can be incidentally found in a hernia sac should simplify future diagnoses. Immunohistochemistry is helpful in making the correct diagnosis.

De Garengeot's hernia: acute appendicitis in a femoral hernia. Case report and literature overview

Migration of the appendix vermiformis into a femoral hernia is also known as De Garengeot's hernia. We report the case of an elderly patient who was diagnosed with an acute appendicitis within a strangulated femoral hernia sac. Emergency incision and abscess drainage was performed, followed by delayed laparoscopic appendectomy and herniorraphy. Both procedures were uneventful and the patient fully recovered. Although exceedingly rare, the surgeon needs to be aware of this entity to prevent a delay in diagnosis with potentially serious adverse events.

A rare case of acute abdomen: Garengeot hernia

The association of acute appendicitis with femoral hernia,strangulated or incarcerated, represents a rare but well documented pathology in the specialized medical literature,also known as Garengeot hernia. The development of an acute appendicitis in the femoral hernia sac becomes a surgical emergency of acute abdomen. The diagnosis is always mistaken for the one of incarcerated or strangled hernia, the correct diagnosis being established intraoperatively, occasion which exposes the cecal appendix by opening the herniary bag, found in different morphological stages of inflammation that can go as far as gangrene or even perforation. In this paper, we have reported the case of a 76 year-old female that presented with femoral tumours, incarcerated, painful and initially considered as an incarcerated femoral hernia, the final diagnosis being made intraoperatively. The treatment for these "hernias" is generally simple, when there are no complications of acute appendicitis as the presence of pus in the hernia sac, and consists in appendectomy and herniorrhaphy. The absence of symptoms for an acute appendicitis often delays the surgery which leads to frequent complications and increased rate of morbidity.

Laparoscopic appendectomy combined with TEP for de Garengeot hernia: case report

INTRODUCTION

A de Garengeot hernia is defined as a femoral hernia containing the vermiform appendix. De Garengeot hernia is a rare condition, reported to occur in only 0.8% of all femoral hernias. Acute appendicitis presenting within a femoral hernia is even rarer, occuring in 0.08-0.13% of all cases of acute appendicitis.

CASE REPORT

We present the case of a 64-year-old woman with the diagnosis of incarcerated groin hernia. An urgent laparoscopy was performed showing the distal part of the appendix passing through a small right-sided femoral hernia. A laparoscopic appendectomy was performed, followed by TEP-procedure for femoral hernia repair.

DISCUSSION

To our knowledge, this is the first report of this type of approach for a de Garengeot hernia.

[Incarcerated De Garengeots hernia complicated by gangrenous appendicitis]

Femoral hernias account for only about 0.7% of all operated hernias and are rather infrequent among male patients. By contrast, acute appendicitis is one of the most frequent diagnoses in surgery requiring urgent operation. The authors present one of the rare cases in which both these diagnoses occur together - De Garengeots hernia. Incarcerated femoral hernia with acute appendicitis is diagnosed preoperatively only sporadically. Imaging methods can help in the diagnosis, but often the final diagnosis, and especially the final solution, is brought about only by surgical intervention.

De Garengeot hernia with acute appendicitis

AIM

The presence of the appendix within a femoral hernia sac is a rare condition known as De Garengeot hernia. We report a case of De Garengeot hernia with concomitant appendicitis and a brief review of the literature on the pathogenesis, diagnosis and treatment of this uncommon condition.

CASE REPORT

A 33 year-old woman was admitted to our Surgical Unit with acute-onset pain and swelling in the right groin region. Clinical signs and ultrasound imaging suggested the presence of a strangulated femoral hernia and the patient was operated on in emergency setting. An inflamed appendix was discovered within the hernia sac. Appendectomy via McBurney incision and prosthetic repair of the femoral ring were performed. The postoperative course was uneventful and at the 2 week and 1 year follow-up no signs of wound infection and no hernia recurrence were found.

CONCLUSION

Since clinical signs are non-specific and radiological findings may often be misinterpreted, appendicitis within a femoral hernia sac is often an incidental finding during an emergency operation for strangulated femoral hernia. Appendectomy-associated hernia repair may be performed with or without prosthesis depending on the extent of surgical field contamination.

De Garengeot's hernia: an unusual right groin mass due to acute appendicitis in an incarcerated femoral hernia

The presence of an acutely inflamed vermiform appendix in a femoral hernia sac is extremely rare; the condition is termed De Garengeot's hernia. Here we describe an elderly patient for whom preoperative computed tomography aided the diagnosis of this rare entity. This Chinese woman had presented with a painful right groin mass. The patient successfully underwent an emergency appendicectomy and primary femoral hernia repair. Once diagnosed, it is imperative to follow key surgical principles to limit the spread of infection.

Bowel prolapse following spontaneous rupture of a femoral hernia

This case presents a rare complication of the spontaneous rupture of a femoral hernia in an elderly woman without causing much systemic effect despite the herniated bowel being necrosed and perforated, giving rise to an enterocutaneous fistula. The small bowel had also prolapsed through the fistula opening, making it a very rare and alarming presentation.

Meckel's diverticulum in a strangulated femoral hernia. Case report and review of literature

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. In the vast majority of cases it remains asymptomatic throughout life but in about 5% of cases it gives rise to complications, namely, haemorrhage, intestinal obstruction and inflammation. A rare complication is being presented--a femoral hernia containing a strangulated Meckel's diverticulum. This is known as Littre's hernia, which often exhibits subtle variations from the norm in its presentation. Preoperative diagnosis of Littre's hernia containing Meckel's diverticulum is rather difficult; almost always, the strangulated diverticulum is first discovered during operation. The diverticulum was resected and the femoral canal closed by a polypropylene mesh plug. The patient underwent an uneventful recovery and was discharged home on the fourth postoperative day. Complications arising from Meckel's diverticulum usually occur at a young age, with the ectopic tissue present in the diverticulum frequently being the cause of the symptoms. Criteria for the resection of Meckel's diverticulum found incidentally at laparotomy have been suggested.

[Enterocutaneous fistula caused by strangulated groin hernia: five cases in Morocco]

The purpose of this report is to describe 5 cases of strangulated hernia discovered in patients presenting with enterocutaneous fistula. Most patients were women with small femoral hernias.

[Elderly women with abdominal pain due to an incarcerated 'femoral hernia']

Symptoms and findings during physical examination of patients with a femoral hernia are notoriously aspecific. Signs in the inguinal region tend to be overlooked, particularly in obese patients. Three women aged 72, 83 and 68, presented with abdominal pain and ileus due to incarcerated femoral hernias. A correct diagnosis was not considered prior to emergency laparotomy. One progressively septic patient with disseminated breast cancer refused reintervention after successful correction of the femoral hernia, and succumbed. The other two recovered uneventfully. Any older female patient with recurrent abdominal complaints may harbour a femoral hernia. The inguinal region should be examined, if possible in the upright position. Ultrasound, CT or MRI scans should establish the diagnosis. Open or laparoscopic intervention is required in patients fit for surgery since incarceration of a femoral hernia is associated with considerable morbidity and even mortality.

[Appendix incarcerated in femoral hernia--case report]

We describe a rare case of incercerated femoral hernia containing appendix. Femoral hernias are quite rare comparing to inguinal hernias, and might be more difficult to doagnose. During diagnosis and differentiation of femoral hernia possible cimplications such as incarceration of urinary bladder or intestin must be considered.

[A case of intestinal obstruction caused by strangulated femoral hernia accompanying soft tissue necrosis]

Intestinal obstruction involves a partial or complete blockage of the bowel which results in the failure of intestinal contents to pass through. The mechanical causes of obstruction may include the followings: hernias, postoperative adhesions or scar tissue, impacted feces, gallstones, tumors, granulomatous processes, intussusception, volvulus, foreign bodies, and etc. Hernias are the third leading cause of intestinal obstruction by 10% approximately. However, most hernias are the cases with abdominal wall, inguinal or internal hernia. Femoral, obturator, lumbar, or sciatic hernia as the cause of obsturction is rare. Furthermore, the cases accompanying soft tissue necrosis are seldomly reported. Herein, we report a case of intestinal obstruction caused by strangulated femoral hernia accompanying soft tissue necrosis in a 78-years-old female patient.

[Acute appendicitis in a femoral hernia]

INTRODUCTION

Acute appendicitis in a femoral hernia is an uncommon condition that can be serious. Complications are more frequent if the diagnosis is delayed and surgery is not performed on time.

CASE REPORT

We present a 71-year-old man with a painful swollen mass. The patient presented with fatigue and loss of appetite, while body temperature was normal. The abdomen was not painful, and peristaltic was normal. All laboratory findings were normal. After anamnesis and physical examination, the presumed diagnosis was incarcerated femoral hernia and the patient was sent to the operating room. Intraoperative findings revealed an incarcerated femoral hernia within a phlegmonous inflammated appendix. Appendectomy and McVay hernioplastics were done. The postoperative course was without complications.

CONCLUSION

It is very important to bear in mind that right femoral hernia with signs of incarceration and inflammation may contain an acutely inflamed appendix. Delayed diagnosis and misdiagnosis cause greater morbidity and mortality.

De Garengeot hernia: an analysis of our experience

AIM

The presence of a vermiform appendix in a femoral hernia sac is termed De Garengeot hernia. It may present as a tender and/or erythematous groin swelling and is often misdiagnosed as an incarcerated or strangulated femoral hernia. The purpose of this study is to review the management of De Garengeot hernia at a single institution since 1991.

MATERIALS AND METHODS

A retrospective analysis of seven consecutive patients operated upon at our institution from 1991 to 2006 with De Garengeot hernia was undertaken. Patients' demographics, treatment performed and postoperative outcome were analysed.

RESULTS

There were three men and four women. The median age was 55 years. None of the patients were diagnosed preoperatively. The commonest presenting symptom was painful groin swelling. All patients therefore underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated femoral hernia. Operative findings included four normal appendices, two inflamed appendices and one perforated appendix in the femoral hernial sac. Patients with normal appendix (n = 4) had mesh hernia repair without an appendicectomy. The rest of the patients (n = 3) with abnormal appendix underwent emergency open appendicectomy followed by sutured hernia repair. We had no deaths in this series and one minor wound infection. No recurrent hernia has been detected to date.

CONCLUSION

Inflammation of the appendix determines the type of hernia repair and surgical approach. Incidental appendicectomy in the case of a normal appendix is not preferred.

[The Aymand's hernia. Case report and review of the literature]

The crural hernia containing an inflamed appendix is a rare entity and must be considered a variant of the hernia first described in 1735 by Claudius Amyand. This hernia is rarely recognised and diagnosed before the surgical treatment because it is often confused with a strangled hernia. In spite of this, the clinical presentation seems to follow a well determined pathway, so is possible to argue that the uncorrect diagnosis is to be attributed to the ignorance of this hernia. We report a case of Amyand's crural hernia in a woman 57 years old. The base of the appendix was not inflamed and, according to this, we made an appendectomy. We closed the hernia defect without the use of a synthetic mesh. The post operative period was regular and free of complications.

Laparoscopic repair of a Littre's hernia with porcine dermal collagen implant (Permacol)

BACKGROUND

Littre's hernia was originally defined as "the presence of a Meckel's diverticulum in any hernia sac" by Rieke in 1841. It is a rare finding at any age, and its true incidence is unknown. The conventional treatment for Littre's hernia is wedge resection of the diverticulum and repair of the hernia from within the sac. However, the advent of laparoscopic surgery has altered the management of all abdominal hernias, including Littre's hernia.

CASE REPORT

We present a case of a 55-year-old woman who presented as an emergency with right iliac fossa pain and tenderness. A CT scan demonstrated a 46 x 25 x 25 mm lesion related to the distal ileum extending towards the inguinal canal. At laparoscopy she was found to have a Meckel's diverticulum herniating through the deep inguinal ring into the right inguinal canal. We report the laparoscopic excision of the Meckel's diverticulum using an endoscopic stapling device and repair of this hernia with Permacol, an acellular porcine collagen mesh. The patient made a quick recovery and was discharged 5 days post-operatively. A complication of an umbilical port site infection was treated 2 weeks post-operatively with oral antibiotics. To date there has been no recurrence of the hernia and no right inguinal pain. Laparoscopic repair of Littre's hernia using Permacol has not been reported previously.

CONCLUSIONS

Laparoscopy is a safe, inexpensive and efficient method for the diagnosis and treatment of Littre's hernia. Permacol is a strong yet supple material for hernia repair.

Inguinofemoral Hernia: Accuracy of Sonography in Patients with Indeterminate Clinical Features

OBJECTIVE

The objective of our study was to investigate the accuracy of sonography in patients with symptoms suggestive of a hernia and normal or equivocal clinical examination findings.

SUBJECTS AND METHODS

Fifty-nine consecutive patients (47 men, 12 women; median age, 51 years; range, 19-82 years) were enrolled in a prospective study of sonography and herniography for investigation of inguinofemoral pain. All patients were referred with a history suggestive of hernia but with equivocal clinical features by three experienced surgeons. All patients underwent sonography and herniography examinations performed by experienced radiologists blinded to clinical details. The imaging variables recorded for each side were normal (including posterior inguinal wall bulging), hernia (indirect, direct, femoral, and abdominal wall), or nondiagnostic. The percentage of exact agreement, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for sonography and herniography and were compared with surgery when performed; then all sides for sonography were compared with herniography.

RESULTS

Surgery was performed in 18 patients (31%) on 21 sides and found hernia (n = 20) and patulous posterior inguinal wall (with no hernia) (n = 1). Compared with surgery, the results of sonography versus herniography, respectively, were exact agreement (91% vs 71%), sensitivity (95% vs 70%), specificity (100% vs 100%), PPV (100% vs 100%), and NPV (50% vs 14%). The sensitivity of sonography was significantly higher than that of herniography (McNemar test, p = 0.025). Both techniques had one false-negative in the same patient. Herniography had five additional false-negatives identified as hernias at sonography and surgery. Compared with herniography as the reference, the sonography findings were in exact agreement in 91% (107/118) of the cases; and sensitivity was 90% (19/21); specificity, 91% (88/97); PPV, 68% (19/28); and NPV, 98% (88/90).

CONCLUSION

Sonography is an accurate technique for the detection of inguinofemoral hernias in patients with clinically equivocal findings.

Acute appendicitis in an incarcerated crural hernia: analysis of our experience

INTRODUCTION

The finding of the vermiform appendix within a crural hernia (Amyand s hernia) is a rare entity whose incidence is not described in the literature.

OBJECTIVE

The aim of this study was to report our hospital s experience in this kind of pathology.

MATERIAL AND METHODS

Between 1993 and 2004, 4,572 acute appendicitis and 372 incarcerated crural hernia cases have been operated on in our hospital. We studied 6 cases of incarcerated crural hernia with vermiform appendix inside. We analyzed in retrospect the following parameters: age, sex, personal history, clinical manifestations, preoperative diagnosis, surgical technique, mean hospital stay, and outcome.

RESULTS

All patients were women with a mean age of 78.8 years. Most frequent clinical manifestations included pain and a mass in the right inguinocrural region, of variable intensity and duration. No clinical, laboratory, or radiographic signs help in reaching a correct preoperative diagnosis. General anesthesia and a crural approach are used in most surgical operations. In all cases an appendectomy was performed via the hernia sac, thus proving the presence of acute appendicitis in four of them (66.67%). A prosthetic mesh was used in 3 cases, and one case of wound infection was found. In the other cases we sutured the hernia ring using prolene.

CONCLUSION

The finding of the appendix in an incarcerated crural hernia is a rare entity in old women that is difficult to diagnose preoperatively. Treatment includes appendectomy and herniorraphy. The use of prosthetic mesh is controversial.

A rare cause of intestinal obstruction: incarcerated femoral hernia, strangulated obturator hernia

Obturator hernia may occur bilaterally in association with another hernia, which is usually of the femoral type. We present a 77-year-old-woman who had abdominal pain with nausea and vomiting together with swelling of the right groin for 3 days. Incarcerated right femoral hernia and consequent mechanical small-bowel obstruction was diagnosed, and urgent operation was undertaken. As the incarcerated femoral hernia reduced spontaneously during the induction of anesthesia, a lower median incision was performed. During exploration, the real cause of mechanical intestinal obstruction was found to be a small intestinal loop strangulated in the left obturator hernia. Right femoral and left obturator hernia were repaired with preperitoneal polypropylene mesh. If there is enough time and general condition of the older patient is suitable, further diagnostic techniques for concomitant obturator hernias may be useful in patients who present with signs of incarcerated inguinal hernia and intestinal obstruction.

Strangulated femoral hernia presenting as parietal wall emphysema

Surgical emphysema of abdominal and thoracic wall, along with features of intestinal obstruction, has not been reported as a complication of strangulated femoral hernia. We report a 31-year-old woman with such a presentation.