De Garengeot’s Hernia: Two Case Reports with Correct Preoperative Identification of the Vermiform Appendix in the Hernia

Abstract

We present two cases of incarcerated de Garengeot's hernia. This anatomical phenomenon is thought to occur in as few as 0.5% of femoral hernia cases and is a rare cause of acute appendicitis. Risk factors include a long pelvic appendix, abnormal embryological bowel rotation, and a large mobile caecum. In earlier reports operative treatment invariably involves simultaneous appendicectomy and femoral hernia repair. Both patients were correctly diagnosed preoperatively with computed tomography (CT). Both had open femoral hernia repair, one with appendectomy and one with the appendix left in situ. Both patients recovered without complications. Routine diagnostic imaging modalities such as ultrasonography and standard CT have previously shown little success in identifying de Garengeot's hernia preoperatively. We believe this to be the first documented case of CT with concurrent oral and intravenous contrast being used to confidently and correctly diagnose de Garengeot's hernia prior to surgery. We hope that this case report adds to the growing literature on this condition, which will ultimately allow for more detailed case-control studies and systematic reviews in order to establish gold-standard diagnostic studies and optimal surgical management in future.

A Rare Case of Chronic Appendicitis Superimposed on an Incarcerated de Garengeot Hernia Prospectively Identified on Computed Tomography

“…The diagnosis of a DGH is difficult to make preoperatively, and only 4 reports of a preoperative CT diagnosis having been reported in the literature to date; herein, we present the fifth case [ 1 , 4 – 6 , 15 ]. In a review of DGHs by Kalles and colleagues, preoperative CT scanning was obtained in 9 patients; however, in only 4 cases was the CT diagnostic for a DGH [ 9 , 11 ].…”

“…In 2005, Akopian and Alexander first termed a femoral hernia containing the appendix the de Garengeot hernia (DGH) after French surgeon Rene de Garengeot, who is credited as the first to describe this entity in 1731 [ 1 , 2 ]. To date, there are a total of fewer than 100 cases of DGH reported in literature with only 4 cases prospectively identifying the DGH prior to surgical intervention [ 1 , 3 – 8 ]. DGHs are typically an incidental and unexpected finding discovered during femoral hernia repairs with an incidence in less than 1% of surgically treated hernias [ 4 , 7 ].…”

Treatment of de Garengeot’s hernia: a meta-analysis

“…It has been estimated there are between 100 and 200 patients in the literature [36, 74], but the exact figure is difficult to calculate. A frequency of 0.8%, accounting for 0.13% of all appendicitis, as reported in the literature, therefore, appears too high [36]. Thus, large register data are needed to assess the true incidence of de Garengeot’s hernia.…”

“…The entrance to the femoral canal, the femoral ring, is located posterior to the inguinal ligament, anterior to the pectineal ligament, lateral to the lacunar ligament, and is medial to the femoral vein. The femoral ring is narrow, fibrotic, and the limited space within the hernia increases the risk of incarceration [10, 36, 52]. Incarceration of the appendix in a femoral hernia may be promoted by a large caecum, a caecum positioned low in the pelvis, or an abnormal intestinal rotation [20, 65, 71].…”

De Garengeot’s hernia: a rare presentation of the wandering appendix

“…Preoperative diagnosis based on clinical ground is usually that of an incarcerated femoral hernia with or without bowel obstruction depending on the presentation 4. Imaging modalities are increasingly reported to be useful in the preoperative period specially with CT scanning as clinical examination alone has a limited value in determining the contents of the sac; however, in most instances, the diagnosis was made intraoperatively like in our case 5. Unlike in our case, where CT scan was not able to provide a diagnosis of the femoral hernia, it has been reported in literature to have a success rate in picking up the femoral hernia with the appendix in the sac in 44% of the patients 3.…”