Appendicitis in De Garengeot's Hernia Presenting as a Nontender Inguinal Mass: Case Report and Review of the Literature

Introduction. De Garengeot first described a femoral hernia containing the appendix in 1731. Appendicitis occurring in this rare clinical setting represents a challenge in diagnosis and management. Case Presentation. We present the case of a 71-year-old male with a three-day history of a nontender inguinal mass. Computed tomography (CT) suggested a femoral hernia. Intraoperatively, the hernia sac was noted to contain a perforated appendix. Discussion. This is an infrequently reported clinical scenario and only the 14th reported case in peer-reviewed literature which includes preoperative CT images. Our case adds to previously reported low sensitivity of CT for diagnosing De Garengeot’s hernia. Furthermore, unlike our case the vast majority of previous reports noted a painful inguinal swelling. Conclusion. Perforated appendicitis in a femoral hernia is an extremely uncommon presentation. However, consideration should be given to De Garengeot’s hernia in patients with a groin mass, even if nontender. 1. Introduction De Garengeot’s hernia is named after the 18th century Parisian surgeon Rene Jacques Croissant De Garengeot (1688–1759) [1]. This hernia was first described in 1731 and describes a femoral hernia including the appendix within the hernia sac. This is a rare presentation with the appendix present in only 0.8% of femoral hernias [1]. Appendicitis occurring in this rare clinical setting represents a challenge in diagnosis and management. To the authors’ knowledge, there have been only 13 reported cases in published peer-reviewed literature with preoperative computed tomography (CT) imaging. Nine of these cases were included in one comprehensive review [2]. 2. Case Report A 71-year-old male was referred by his general practitioner to a tertiary hospital surgical assessment unit with query right groin lymphadenopathy. The patient reported a three-day history of painless swelling in his right groin. Physical exam revealed a firm irreducible nontender mass in his right groin. There was no cough impulse present. His abdominal exam was otherwise soft and nontender. The patient was afebrile, normotensive and was not tachycardic with a heart rate of 98. Serological investigations revealed that leukocyte count was 11.4？×？109/L. Renal and liver function tests were within normal limits. The provisional diagnosis was one of right inguinal lymphadenopathy. Computed tomography (CT) imaging was arranged (Figure 1). The CT report described a right femoral hernia containing omentum. The patient was then scheduled for emergency incarcerated femoral hernia repair.