Balakrishnan, Santosh

Doddi, Sudeendra

Sagar, Vishal

Singhal, Tarun

Sinha, Prakash

Smedley, Frank

English

PubMed

Sudeendra Doddi

Vishal  Sagar

Tarun Singhal

Santosh Balakrishnan

Frank Smedley

Prakash Sinha

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Case Reports in Medicine

Femoral Hernia with a Twist

Vishal Sagar

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Hindawi Publishing CorporationCase Reports in MedicineVolume 2010, Article ID 650829, 3 pagesdoi:10.1155/2010/650829Case ReportFemoral Hernia with a TwistSudeendra Doddi, Vishal Sagar, Tarun Singhal, Santosh Balakrishnan,Frank Smedley, and Prakash SinhaPrincess Royal University Hospital, Farnborough Common, Orpington, Greater London BR6 8ND, UKCorrespondence should be addressed to Sudeendra Doddi, sdoddi@nhs.netReceived 11 February 2010; Revised 23 June 2010; Accepted 12 July 2010Academic Editor: Curtis W. SlipmanCopyright © 2010 Sudeendra Doddi et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.1. IntroductionIn England, there were 4500 cases of femoral hernia for theyear 2005-2006, accounting for 3.5% of all herniae [1]. Thefemoral hernial sac contents may be varied: preperitonealfat, omentum, small bowel, or colon. In rare instances,the appendix can be found in the hernial sac, a reportedincidence of 0.8%. Whether inflamed or not, the findingof vermiform appendix inside a hernia sac is known asAmyand’s Hernia, and it classically refers to an inguinalhernia. Claudius Amyand (1681–1740), a French refugeein England, was one of the leading surgeons of his day;and held the accolade of being surgeon to George II ofEngland. In 1735 he was the first to note the presence ofa perforated appendix within the inguinal hernia sac inan eleven-year-old boy, and he subsequently performed asuccessful appendicectomy(Hutchinson, 1993; Franko andSulkowki, 2002). Acute appendicitis in a femoral hernia isa rare, potentially serious complication. The presence of avermiform appendix in a femoral hernia sac is termed DeGarengeot hernia after Rene Jacques Croissant de Garengeot,an 18th century Parisian surgeon, who is quoted in theliterature as the first to describe an appendix in a femoralhernia sac.It presents as an incarcerated or strangulated hernia, andthe surgical management is diﬀerent for the two conditions.Prompt surgery is needed to avoid complications. Awarenessof this condition may help to avoid delay in management.We report a case of a patient with an acute appendicitisin a right femoral hernia presenting with a painful groinmass.2. Case StudyAn independent 94-year-old Caucasian male presented as anemergency with a two-day history of progressive right groinpain. He did not have fever, nausea, anorexia, or obstructivesymptoms. He had previously undergone multiple bilateralinguinal hernia repairs. He had history of noninsulin-dependent diabetes, chronic obstructive pulmonary dis-ease, previous pneumonias, and metatarsalgia. Medicationsincluded aminophylline, zopiclone, prednisolone, salbuta-mol, metformin, and montelukast sodium.The general, cardiovascular, and respiratory examina-tions were normal. Abdominal examination revealed a tenderlump in the right groin measuring 2 cm in diameter thatwas irreducible. However, a cough impulse could not bedemonstrated, and the overlying skin was not erythematous.The abdomen was scaphoid, soft, and with no guarding orrigidity. Rectal examination was normal.A full blood count showed Haemoglobin 11.4 g/dL andwhite blood cells 7.8 × 109/L. Urea, electrolytes, and liverfunction were reported as normal. ESR was mildly raisedat 51, and the CRP was normal. Erect chest and supineabdominal X-rays were also normal.At this time, a presumptive diagnosis of irreducibleright recurrent inguinal hernia was made. The patient wasadmitted, kept nil by mouth, and given intravenous fluidsand analgesia in preparation for surgery.Ultrasound scan revealed a right indirect inguinal herniacontaining one bowel loop and fatty omentum, but it was notpossible to determine whether strangulation had taken place(Figure 1).2 Case Reports in MedicineThe patient underwent surgery under a general anaes-thetic. A right groin incision was made; a femoral herniasac was identified, and dissected by a low approach. Onopening the sac, an inflamed, incarcerated appendix wasidentified (Figure 2). An appendicectomy was performedthrough the same incision. The femoral canal defect wasclosed with a primary suture repair. In view of the age ofthe patient, finding a femoral hernia intraoperatively andan inflamed appendix, a “low approach” was undertakento repair the femoral hernia. Postoperatively, the patientmade an uneventful recovery. He was discharged home threedays after surgery. The histology of the appendix confirmedappendicitis.3. DiscussionFemoral herniae account for 4% of all groin herniae andare more common in women and with increasing age[2]. Femoral herniae have the highest rate of incarcerationamongst groin herniae, 5%–20% [3], because of the narrowand rigid femoral canal and therefore require early surgicalrepair. Although most groin masses are simple hernia,occasionally these hernia contain more than just smallintestines. Stomach, omentum, colon, and an appendix haveall been reported as contents. The latter has an incidenceof 0.5%–5% [4]. The appendix is found in the femoralhernial sac more commonly during elective hernia repairthan emergency repair [2–5]. The appendix may be inan abnormal anatomical site because of intestinal rotation,variable attachment of caecum, or a large caecum extendinginto the pelvis [3]. Acute appendicitis within an externalhernia is rare—it accounts for 0.13% of all cases of acuteappendicitis. Acute appendicitis in a femoral hernia sac isextraordinarily rare—there have been just over 70 casesreported to date [2].Intraabdominal appendicitis is thought to be due tointraluminal obstruction secondary to appendicolith orlymph node hypertrophy. In contrast, appendicitis in afemoral hernia is due to extraluminal compression from anarrow and rigid canal. Probably for this reason appendicitisis more common in femoral herniae than other groin herniae[5]. For the same reason there is no intraperitoneal spreadof infection, and patients present with local signs such aserythema and groin tenderness rather than peritonitis.The commonest presentation is that of a strangulatedfemoral hernia. It can sometimes present as necrotisingfasciitis or small bowel obstruction. The cardinal features ofappendicitis are usually absent [6].Sharma et al. [4], in their retrospective analysis of sevenconsecutive patients with De Garengeot hernia, found thatnone of the patients were diagnosed preoperatively, andall patients therefore underwent emergency surgery with apresumptive diagnosis of either incarcerated or strangulatedfemoral hernia. There are only two case reports of appen-dicitis in a strangulated femoral hernia being diagnosed pre-operatively on CT scan [3, 7]. Though these two studiesconsidered CT scan to be highly specific and sensitive,routine use of imaging pre-operatively is not feasible becauseFigure 1: Preoperative ultrasound scan of right groin swellingshowing a presumed indirect inguinal hernia containing one bowelloop and fatty omentum.Figure 2: Intraoperative picture from exploration of femoral herniasac. The acutely inflamed appendix has been delivered out.of the rarity of the condition and the need to expedite surgeryto avoid complications.Although well defined and previously discussed, it stillbaﬄes most junior surgeons to find an appendix incarceratedwithin a femoral hernia. There is a need to deal with the con-tent of the hernia, whilst at the same time perform a safe anddefinitive repair in the face of potential infection due to thenature of the contents. Due to paucity of cases no standardtreatment exists. Sharma et al. advocated mesh hernia repairwithout an appendicectomy in the case of a normal appendixand open appendicectomy followed by sutured hernia repairwhen the appendix was inflamed. It would be safer toperform an appendicectomy if the appendix is inflamed,perforated, or appearing to be congested. It is feasible inmostcases to deliver the appendix out completely through thehernia sac itself after identifying the content and dissectingthe strangulated neck of the sac. In cases where mobilisationof the sac and contents is diﬃcult to achieve through a lowgroin approach, it may be safer to gain additional approachthrough a low right paramedian incision or cosmeticallysuperior Pfannenstiel incision to achieve reduction and per-form an appendicectomy. A normal appendix can howeverbe safely returned into the abdominal cavity followed by astandard mesh or plug-based tension-free hernia repair.Case Reports in Medicine 3There is no clear consensus on the use of mesh. Moststudies recommend primary tissue repair [4, 5]. However,when there is a groin hernia abscess caused by perforatedappendix, some authors advocate incision and drainage withdelayed appendectomy and hernia repair [5]. Some authorshave mentioned the use of a mesh when the appendixwas inflamed in a femoral hernia and reported no woundinfection [4, 8]. The main concern is wound infection whichis thought to be as high as 29% in view of the delay indiagnosis and old age of the patients [5, 8, 9].4. ConclusionIncarceration of the vermiform appendix in a femoral herniais a rare clinical event. Despite the rarity, one should be awareof this condition to minimise morbidity. Appendicectomyis performed after obtaining adequate exposure. The risk ofwound infection favours a tissue-based suture repair thoughin select cases a mesh may be used.References[1] HES online, NHS, London, UK. 2005-2006.[2] G. Akopian and M. Alexander, “De Garengeot hernia: appen-dicitis within a femoral hernia,” American Surgeon, vol. 71, no.6, pp. 526–527, 2005.[3] R. Zissin, O. Brautbar, and M. Shapiro-Feinberg, “CT diagnosisof acute appendicitis in a femoral hernia,” British Journal ofRadiology, vol. 73, no. 873, pp. 1013–1014, 2000.[4] H. Sharma, P. K. Jha, N. S. Shekhawat, B. Memon, and M. A.Memon, “De Garengeot hernia: an analysis of our experience,”Hernia, vol. 11, no. 3, pp. 235–238, 2007.[5] E. T. Nguyen and I. K. Komenaka, “Strangulated femoral herniacontaining a perforated appendix,” Canadian Journal of Surgery,vol. 47, no. 1, pp. 68–69, 2004.[6] A. Suppiah, J. Barandiaran, R. Morgan, and E. P. Perry, “Firstcase of villous adenoma of the appendix leading to acuteappendicitis presenting as strangulated femoral hernia: changesinmanagement owing to concurrent adenoma,” Hernia, vol. 12,no. 1, pp. 95–98, 2008.[7] Y. Fukukura and S. D. Chang, “Acute appendicitis within afemoral hernia: multidetector CT findings,” Abdominal Imag-ing, vol. 30, no. 5, pp. 620–622, 2005.[8] U. Barbaros, O. Asoglu, R. Seven, and M. Kalayci, “Appendicitisin incarcerated femoral hernia,” Hernia, vol. 8, no. 3, pp. 281–282, 2004.[9] A. J. Voitk, J. K. Macfarlane, and R. L. Estrada, “Rupturedappendicitis in femoral hernias: report of two cases and reviewof the literature,” Annals of Surgery, vol. 179, no. 1, pp. 24–26,1974.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

A .J .V o i t k ,J .K .M a c f a r l a n e ,a n dR .L .E s t r a d a ,“ R u p t u r e d appendicitis in femoral hernias: report of two cases and review of the literature,”

Acute appendicitis within a femoral hernia: multidetector

Appendicitis in incarcerated femoral hernia,”

CT diagnosis of acute appendicitis in a femoral hernia,”

De Garengeot hernia: an analysis of our experience,”

De Garengeot hernia: appendicitis within a femoral hernia,”

First case of villous adenoma of the appendix leading to acute appendicitis presenting as strangulated femoral hernia: changes

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Femoral Hernia with a Twist

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