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

Abstract

Purpose de Garengeot’s hernia is a rare entity in which the appendix is located within a femoral hernia and is almost invariably encountered incarcerated in an emergency setting with concomitant appendicitis. In the literature, there are mostly single-case reports. The purpose of the present study was to perform a review of the literature to study the incidence, pathogenesis, demographics, clinical presentation, laboratory and radiological investigations, differential diagnosis, delay in diagnosis and treatment, operative findings, surgical technique, histological findings, the postoperative course, use of antibiotics, and complications regarding de Garengeot’s hernia. Methods A literature search was performed through PubMed with the following search terms, single or in combination: Garengeot, femoral hernia, and appendicitis. Additional references were also found within the articles, and two patients from Uppsala University Hospital were added. Results Between 1981 and 2016, 70 publications were identified, and with the additional two patients, the present series comprised 90 patients There were 75 women (median age 73.0 years) and 15 men (median age 78.0 years). On examination, an inguinal mass was found in 87 patients (97%), which was painful and the cause of primary complaint in 67 patients (74%): the median duration of symptoms was 3 days. Radiological investigations or ultrasound were performed in 67 patients (74%); computed tomography was the most accurate with a positive diagnosis in 23/34 patients. Appendicitis was found in 76 patients, gangrenous in 23, and perforated in 9. The surgical approach was inguinal in 76 patients, including 15 with concomitant laparotomy. The preperitoneal route was chosen in six patients, and laparoscopy alone in four patients. A mesh/plug was used in 22 patients (7/22 normal appendix) and suture repair in 59 (4/59 normal appendix: p < 0.01). Complications were analysed in 79 patients and occurred in 11%. There was no mortality. Conclusions de Garengeot’s hernia is rare, being indistinguishable from an incarcerated femoral hernia in general. A delay in surgery should be avoided but if needed, computed tomography may be used for differential diagnosis. Although there is no standard treatment, mesh material does not appear advisable in the presence of a perforation, and it is beneficial for the surgeons to perform their routine method rather than a specific technique.

Symptomatic lump during lockdown – A case of de Garengeot’s hernia

“…Although described by de Garengeot in 1731, the first surgical approach to this rarity is attributed to Helvin in 1785 [ 9 ]. The true incidence of de Garengeot’s is difficult to assess, estimates suggest 100–200 hundred patients in the literature [ 10 ]. To our knowledge there is only one other report with ultrasound and computed tomography confirmation of the diagnosis prior to operative intervention [ 4 ].…”

“…The femoral ring is narrow which increases the risk of incarceration of hernias that traverse it [ 10 ]. Proposed migration of the appendix in a femoral hernia include a large caecum pushing the appendix into the femoral canal, a caecum positioned low in the pelvis or an abnormal intestinal rotation during embryological development [ 11 , 12 ].…”

“…Proposed migration of the appendix in a femoral hernia include a large caecum pushing the appendix into the femoral canal, a caecum positioned low in the pelvis or an abnormal intestinal rotation during embryological development [ 11 , 12 ]. The appendicitis resulting from incarceration at the hernia neck rather than by appendicoliths [ 10 ].…”

“…Presentation is variable which at times lead to delayed diagnosis, in a recent meta-analysis by Linder et al the most common finding was a mass in the inguinal region, occurring in 96% of patients [ 10 ]. Peritonism and systemic symptoms due to underlying appendicitis is limited due to the nature of the femoral canal which keeps the ongoing inflammatory process isolated [ 12 ].…”

Rare Presentations of Hernia

“…Femoral hernia, having less content compared with an inguinal hernia, makes finding an appendix even more remote. However, recurrences for femoral hernia are much less without use of prosthetic mesh and therefore, in the appropriate clinical setting, a combined appendectomy and femoral hernia repair would be having less long-term complications [21].…”