[De Garengeot hernia - a case report].

We report a case of a 79-year-old woman with a previous history of polycythemia vera, glaucoma and hypertension. Her previous surgeries included a cholecystectomy with an incidental finding of a gallbladder carcinoma with following partial liver resection and a hysterectomy. The surgery department was consulted regarding this patient due to abdominal pain in her lower abdomen and tumor in her right groin. A CT scan of the abdomen was obtained that showed a hernia with the appendix vermiformis in the hernia sac. She was operated with a preperitoneal open approach and an inflamed appendix from a femoral hernia sac was removed and a herniorrhaphy with a mesh was performed. The patient was discharged the day after the surgery. Femoral hernia with the appendix in the hernia sac is a rare type of hernia first descriped by Rene-Jacques De Garengeot in 1731 and now bearing his name.

Point-of Care Ultrasound in Stratifying Clinically Evolving Inguinal and Femoral Hernias.

BACKGROUND: Point-of-care ultrasound (POCUS) is an optimal imaging modality for the risk stratification of patients presenting to the emergency department (ED) with inguinal and femoral hernias, allowing for better evaluation of clinical presentations and guiding appropriate treatment. The lack of ultrasound classification for inguinal and femoral hernias has led to inconsistent use and often underuse of POCUS in this patient population. Several groin hernia classifications are available, but most are complex and often targeted toward surgical management. OBJECTIVES: The objective of this study is to review the use of POCUS in the diagnosis of inguinal and femoral hernias, providing a synopsis of critical ultrasound findings in determining signs of incarceration, strangulation, and small bowel obstruction, and suggesting a simple and educative sonographic classification for inguinal or femoral hernias. DISCUSSION: POCUS can reliably confirm the presence of groin hernias and can uniquely identify specific ultrasound findings predictive of complications, such as aperistaltic nonreducible bowel loops, free fluid in the hernia sac, and lack of color doppler in the entrapped mesentery and bowel walls. POCUS can also aid in determining the presence of small bowel obstruction by detecting dilated loops of bowel >25 mm adjacent and proximal to the hernia site. CONCLUSIONS: In the ED, POCUS can confirm the presence of a hernia sac and identify and predict surgical emergencies, such as bowel incarceration or strangulation, which are the most important elements in the management of patients presenting with possible inguinal or femoral hernias.

Atypical femoral hernia called Laugier's hernia: clinical features, radiological findings, and management at a single center.

PURPOSE: Laugier's hernia is a rare clinical entity compared with a typical femoral hernia. Therefore, the clinical features, radiological findings, and appropriate treatment strategies remain largely unclear. In this study, we present 15 Laugier's hernia cases. Additionally, we review the relevant literature and discuss the clinical features, radiological findings, and appropriate treatment strategies pertaining to Laugier's hernia compared with a typical femoral hernia. METHODS: Among 1260 hernia patients, we retrospectively enrolled 15 Laugier's hernia patients (1.19%) and 89 femoral hernia patients (7.06%) who underwent herniorrhaphy and compared the demographic characteristics and radiological findings between the two groups. RESULTS: Regarding the patient characteristics, a significant difference was observed in the presence of pain (p < 0.001) and ileus symptoms (p = 0.001). Regarding the hernia characteristics, significant differences were observed in the size of the hernial sac (p = 0.001), contents of the hernial sac (p = 0.003), repositioning of the hernial sac (p < 0.001), and repair with polypropylene mesh (p < 0.001). The characteristic multi-detector computed tomography (MDCT) findings enabled the preoperative diagnosis of Laugier's hernia versus conventional femoral hernia. CONCLUSION: Surgeons should be alert to the possibility of atypical femoral hernias while examining femoral hernia or inguinal hernia patients. If Laugier's hernia is suspected, preoperative MDCT is recommended.

[Groin hernia in female patients: sex-specific management]. / Hernie inguino-fémorale chez les femmes†: spécificités de prise en charge.

Groin hernia in women is an entity whose clinical manifestations can be quite subtle, and which therefore risks to go unnoticed. Imaging studies by ultrasound or dynamic CT/MRI is strongly recommended in case of a clinical doubt. Optimal treatment consists of laparoscopic surgery, even in oligosymptomatic patients, because the risk of incarceration, and subsequent morbidity and mortality is high especially in cases of femoral hernia, which are frequent and often overlooked in women. During pregnancy, the risk of developing a groin hernia is very low (around 0,1%) and a wait-and-see attitude is to be preferred as much as possible, except in the case of an acute complication (incarceration).

Chez les femmes, la hernie du pli de l'aine est une entité dont les manifestations cliniques peuvent être subtiles, majorant son risque de passer inaperçue. Un bilan d'imagerie, par échographie, voire scanner ou imagerie par résonance magnétique dynamique, est fortement conseillé en cas de doute clinique. Le traitement optimal consiste en une chirurgie par abord laparoscopique, même chez les patientes oligosymptomatiques, car le risque d'incarcération et de morbimortalité est élevé, surtout en cas de hernie fémorale, fréquente et souvent méconnue chez les femmes. Durant la grossesse, le risque de développer une hernie de l'aine est très faible (de l'ordre de 0,1 %) et une attitude attentiste est à privilégier au maximum, sauf en cas de complication aiguë (incarcération).

Lessons learned from an unusual condition of incidental synchronous multiple hernias of indirect inguinal hernia, femoral hernia, and incarcerated obturator hernia.

Hernias are one of the most common diseases. The frequency of multiple hernias is much higher than the frequency reported during herniorrhaphy. Multiple hernias may account for some of the so-called recurrences, in which the small hernia may be veiled by the bigger one and omitted. In this study, we present a case of an 83-year-old female who suffered from multiple hernias namely a left-sided indirect inguinal hernia, a right-sided femoral hernia, and a right-sided incarcerated obturator hernia. Additionally, the characteristics and treatment of obturator hernia were discussed. Ultrasound and computed tomography (CT) are capable of accurately diagnosing groin hernia. Preoperative bilateral ultrasound of examinations or abdominopelvic CT should be recommended to perform routinely for patients with suspected hernias to avoid ignoring the concurrent hernias. A careful exploration of the operative field in the operation is mandatory. The CT is also helpful for early diagnosis of obturator hernia. In addition, the intra-abdominal approach through a low midline incision might be a preference for the treatment of obturator hernia.

Acute Appendicitis Involving a De Garengeot Hernia.

We present a case of appendicitis within a De Garengeot hernia. The patient presented to the emergency department with 4 days of worsening abdominal pain. Computed tomography examination revealed an inflamed appendix within a femoral hernia. The patient underwent appendectomy and repair of the femoral defect. Pathological examination was consistent with acute appendicitis. De Garengeot hernia is a rare phenomenon, with less than 5% of femoral hernias containing the appendix and 0.08% to 0.13% containing an incarcerated acute appendicitis.

Effectiveness of Sonography in Detecting Clinically Occult Femoral Hernias.

OBJECTIVES: The aim of this study was to evaluate the accuracy of sonography for femoral hernia diagnosis in patients with suspected hernias that were not evident on clinical examination. METHODS: A retrospective analysis was performed for 39 consecutive patients with 40 clinically suspected but occult femoral hernias and subsequent positive sonographic findings for femoral hernias. Clinical records for all patients were reviewed for surgical outcomes and clinical follow-up. Surgical findings of a femoral hernia sac or widened femoral canal requiring repair, with symptomatic relief after the procedure, were considered positive for a femoral hernia. RESULTS: Among the 40 femoral hernias examined by sonography, 33 of 40 groins underwent surgical exploration, with 32 true-positive findings and 1 false-positive finding on sonography. The false-positive case was an inguinal hernia at surgery. The accuracy of sonography was 96.9% for those with surgical correlations. The remaining 7 patients did not undergo surgery but had clinical follow-up. CONCLUSIONS: This study confirms high diagnostic accuracy of sonography for nonpalpable femoral hernias in symptomatic groins compared to surgical findings.

Role of Sonography in Clinically Occult Femoral Hernias.

OBJECTIVES: The purpose of this article is to evaluate the diagnostic accuracy of sonography in clinically occult femoral hernias and to describe our sonographic technique. METHODS: The clinical and imaging data for 93 outpatients referred by general surgeons, all of whom underwent sonographic evaluation and surgery, were reviewed retrospectively. Of these, 55 patients who underwent surgical exploration for groin hernias within 3 months of sonography and met all inclusion criteria were included in the study. The sonographic technique involves using the pubic tubercle as an osseous landmark to identify and appropriately visualize the femoral canal. The Valsalva maneuver is then used to differentiate the movement of normal fat (a potential pitfall) from true herniation in the femoral canal. Surgical findings were used as the reference standard by which sonographic results were judged. Two-by-two contingency tables were used to calculate the sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: In these 55 patients, surgery revealed 15 femoral hernias. Eight femoral hernias occurred in women, and 7 occurred in men. For diagnosing femoral hernias, sonography demonstrated sensitivity of 80%, specificity of 88%, a positive predictive value of 71%, and a negative predictive value of 92%. True-positive cases of femoral hernias have a sonographic appearance of a hypoechoic sac with speckled internal echoes. When examining during the Valsalva maneuver, a femoral hernia passes deep to the inguinal ligament, expands the femoral canal, displacing the normal canal fat, and effaces the femoral vein. CONCLUSIONS: Sonography can exclude femoral hernias with high confidence in light of its exceptional negative predictive value. With attention to technique and imaging criteria, the diagnostic accuracy of sonography can be enhanced.

De Garengeot hernia: the ultrasound and computed tomographic findings in an 81-year-old woman.

The presence of appendix within a femoral hernia is a rare condition in an incarcerated femoral hernia. It has a characteristic groin mass, and the diagnosis of appendicitis is mainly made intraoperatively. A specific imaging appearance (ultrasonography, computed tomography [CT]) allows accurate prospective diagnosis. The recognition of this rare femoral hernia helps us to choose appropriate therapeutic approach. We report a case of an 81-year-old woman who present with painful and nonreducible groin mass. The ultrasonography and CT characteristic imaging features successfully diagnosed de Garengeot hernia. To our knowledge, this is the first description of a combination of CT and ultrasound in the preoperative diagnosis.

The uncommon preoperative diagnosis of a De Garengeot hernia and its more novel laparoscopic treatment.

This case report involves an elderly woman who presented with a 3-day history of a tender groin swelling on her right side. Her admission bloods were fairly unremarkable, but a preoperative ultrasound impressively confirmed a femoral hernia containing the appendix (De Garengeot hernia) and she underwent emergency laparoscopic hernioplasty with a prosthetic mesh and appendicectomy. The procedure found an incarcerated hernia with a strangulated tip of the appendix that unexpectedly separated upon gentle manipulation and histopathology revealed appendiceal inflammation. There were no complications with the patient's recovery and she was discharged 2 days after surgery.

Bilateral femoral hernia in a five-year-old boy.

Bilateral femoral hernia is extremely rare in children. The diagnosis is challenging, and it often requires multiple surgeries before the correct treatment can be provided. In this case report, a five-year-old boy had two surgeries on suspicion of a right-sided inguinal hernia, but no hernia was found. After the second operation, the suspicion of a hernia was still present. This led to a diagnostic laparoscopy, where a bilateral femoral hernia was found. Laparoscopic McVay procedure was performed on both sides with minor modifications, which consisted of hernia sac plication and fixation to fortify the abdominal wall.

Diagnostic Accuracy of Imaging Modalities on Occult Groin Hernias According to Hernia type and a Surgeon-centered Individualized Groin Hernia Management Algorithm.

BACKGROUND: The purpose of this study is to evaluate the diagnostic performance of imaging techniques for the identification of groin hernias based on the type of hernia and to demonstrate the efficacy of an algorithm based on the surgeon and surgical technique. MATERIALS AND METHODS: Medical records of 561 patients who were operated on for groin hernia were retrospectively analyzed. A total of 102 patients who had both pelvic computed tomography (CT) and ultrasonography (USG) recordings preoperatively and underwent transabdominal preperitoneal repair were included in the study. RESULTS: A contralateral asymptomatic occult groin hernia was detected in 25.5% of all patients. The overall sensitivity of USG and CT on contralateral asymptomatic occult hernia was 42.3% and 65.4%, respectively. The sensitivity of USG according to the contralateral occult hernia type was 66.7%, 35.7%, 33.3%, and 50% for direct, indirect, femoral, and pantaloon hernias, respectively. The sensitivity of CT according to the contralateral occult hernia type was 0%, 57.1%, 100%, and 100% for direct, indirect, femoral, and pantaloon hernias, respectively. CONCLUSIONS: The handicap created by the variability in the diagnostic sensitivity of imaging modalities can be overcome with the choice of transabdominal preperitoneal repair in the surgical technique.

Comparison of patient characteristics and treatment approaches for femoral and inguinal hernias utilizing dynamic ultrasound at a single institution.

PURPOSE: To assess the differences in management approach to femoral versus inguinal hernias and to identify patient characteristics associated with each hernia type. METHODS: Imaging studies for patients who had undergone dynamic ultrasound evaluation for the symptom of groin pain between January 1, 2010, and March 31, 2019, at a single institution Musculoskeletal Department were analyzed. Positive femoral hernia imaging studies were compared to studies for inguinal hernias and matching medical records for imaging studies were analyzed. Association of patient characteristics (age, sex, smoking, diabetes) with hernia type was assessed. Primary outcomes were surgical versus non-surgical approach, type of surgery, number of follow-up visits, and pain resolution. RESULTS: A total of 1319 patients presented with groin pain and were assessed with dynamic ultrasound (534 female; 785 male; mean [± SD] age 48.2 ± 16.5). While 409 (31.0%) patients had a femoral hernia detected, 666 (50.6%) had an inguinal hernia detected (p < .05). Significantly more inguinal hernias were surgically repaired than femoral hernias (65.0% vs 53.9% p = .008), and more inguinal hernias than femoral hernias were treated with open surgery (71.0% vs 57.7%; p = .014). Patients with femoral hernias had significantly more follow-up clinic visits than patients with inguinal hernias (mean [± SD] 2.65 ± 4.80 vs 1.76 ± 1.27; p = .010). No difference in the percentage of patients who had pain resolution was observed (82.2% inguinal vs 75.0% femoral; p = .13). CONCLUSIONS: Femoral hernias were managed more conservatively than inguinal hernias at our institution.

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.

An uncommon entity: De Garengeot hernia.

De Garengeot hernia is a rare type of femoral hernia that presents with appendicitis. This clinical condition that usually occurs in the 7th decade, mostly in women, requires urgent surgery. Here, we present a 73-year-old patient with acute appendicitis within the femoral hernia sac.

Incarcerated femoral hernia containing the right uterine tube. A pre-operative diagnosis is possible.

The incarcerated femoral hernia containing the right uterine tube is very rare to see. The case report is important to accumulate knowledge of very rare cases. The diagnosis of the case was established pre-operatively with abdominal computerized tomography (CT) On CT examination, the mass in the hernia sac was not connected with the intestines and a tubal structure on the right side of the uterus was shown to extend out of the abdomen. In the operation, the right uterine tube(RUT) was reduced into the abdomen after its blood supply was shown to be normal. A hernia repair was performed. Sometimes in obese patients, incarcerated femoral or inguinal hernias may not been noted. Ultrasonography, CT and magnetic resonance imaging (MRI) is used frequently to diagnose abdominal wall hernias. The organs in the incarcerated sac must be examined carefully and the viability must be checked. The surgeon must decide whether or not to resect the organs. In our case, strangulation was not found and polypropylene mesh was not used for hernia repair due to a fear of infection of the prosthesis. Incarceration of the uterine tube in the sac is traumatic and this condition may lead to infection. Such conditions may lead to ectopic pregnancy. The patient must be informed about ectopic pregnancy due to a previous incarceration of the tube because ectopic pregnancy may be fatal.

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.

Sonographic "speech bubble/speech box sign" in clinically occult femoral hernias: ultrasound findings and anatomical basis.

Femoral hernia is the protrusion of a peritoneal sac through the femoral ring into the femoral canal lying deep and inferior to the inguinal ligament. The hernia sac usually contains preperitoneal fat, omentum, bowel, or fluid. Ultrasound is recommended as the first-line investigation for diagnosing clinically occult femoral hernias in nonemergency settings, whereas CT is the imaging of choice in emergency settings. High accuracy of the ultrasound in clinically occult femoral hernia is further validated with further CT and MRI. In this article, we propose sonographic detection of the physiological peritoneal fluid herniating through capacious femoral ring manifesting as a "speech bubble/speech box appearance." This is a potentially invaluable sonographic sign for clinically occult femoral hernias, differentiating them from inguinal hernias and cysts of the canal of Nuck in females and preventing inadvertent attempts to aspirate.