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AUTHOR QUERIES DATE 8/17/2013 JOB NAME TAS ARTICLE 1300121 QUERIES FOR AUTHORS

Brief Reports

THIS QUERY FORM MUST BE RETURNED WITH ALL PROOFS; HOWEVER, PLEASE MARK YOUR CORRECTIONS DIRECTLY ONTO THE PROOFS, NOT ONTO THIS SHEET.

AU1: Provide a legend for Fig. 1.

Brief Reports Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ‘‘Instructions for Authors’’.) They should be no more than 4 double-spaced pages with no Abstract or sub-headings, with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author. In general, authors of case reports should use the Brief Report format.

De Garengeot’s Hernia The presence of an acutely inflamed vermiform appendix in a femoral hernia sac is extremely rare; the condition is termed De Garengeot’s hernia. Preoperative diagnosis of De Garengeot’s hernia is difficult as a result of its atypical clinical presentation. Early diagnosis is important to reduce the morbidity rate. Surgical treatment depends on the surgeon’s sound clinical judgment. The surgical approach should be designed according to the condition of the patient, the anatomical position of the appendix vermiformis, and the likelihood of complications. In this brief report, we present a case of De Garengeot’s hernia. A 49-year-old white woman presented with a 24hour history of sudden-onset painful right-sided groin swelling. On clinical examination, there was a fixed, round, tender mass in the right groin, above the inguinal ligament. Her temperature was 38.9°C and white blood cell count of 16.00 K/mL with 88 per cent neutrophils. A presumptive diagnosis of an incarcerated femoral hernia was made with plans for a right groin exploration using low inguinal incision under general anesthesia. When the hernia sac was opened, an inflamed appendix was seen (Fig. 1). The appendix was thickened and inflamed, but there was no perforation. Routine appendectomy was performed through the hernial sac and the patient had an uneventful postoperative course. Acute appendicitis within a femoral hernia is a rare condition that was first described by Rene Jacques de Garengeot.1 De Garengeot’s hernia is often misdiagnosed as an incarcerated femoral hernia. This phenomenon accounts for 0.8 to 1 per cent of all femoral hernias.1 Patients usually present with a right groin mass, which is almost always painful.1 The groin masses are usually erythematous. Twenty percent of the ultrasound and 44 per cent of the computed tomography studies

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were diagnostic, leading to an overall rate of 14 per cent of femoral hernia appendicitis as a preoperative diagnosis.1, 2 Eighty-one per cent of the patients underwent herniorrhaphy with sutures, whereas mesh was used in 19 per cent. Although the incidence is extremely low, the surgeon should keep it in mind in cases with femoral hernias and regional symptoms of inflammation resulting from the lack of abdominal signs of appendicitis.3 Signs and symptoms of acute appendicitis, however, are often overshadowed by findings of an incarcerated femoral hernia. General abdominal peritonitis is usually absent despite perforation because the tight hernia neck contains the purulent content.2 This suggests that acute appendicitis in femoral hernia may be a consequence of incarceration and strangulation of the appendix rather than the usual internal obstruction resulting from lymph node hypertrophy or an appendicolith. This presentation occurs more commonly in a femoral hernia than in other hernia types as a result of the narrowness and rigidity of the femoral canal. As a result of the paucity of cases, no standard treatment exists, and options tend to vary widely. Appropriate management without incurring any delay for radiological imaging can be promising for an uneventful postoperative course.4 The treatment of choice of this disease entity is emergency surgery and consists of simultaneous appendectomy through

Address correspondence and reprint requests to Demetrios Moris, M.D., Anastasiou Gennadiou 56, 11474, Athens, Greece. E-mail: [email protected].

FIG. 1.

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THE AMERICAN SURGEON

the hernia incision and primary hernia repair.4 In patients with large hernia defects or in older people, the use of mesh for repairing the hernia defect can be an excellent choice.4 In conclusion, a perforated appendicitis in a femoral hernia remains a challenging diagnosis as a result of its extremely rare occurrence. The diagnosis depends on sound clinical judgment and should be considered in elderly women presenting with signs of a strangulated hernia. Diagnostic imaging such as computed tomography can be helpful. The potential for complication in these cases is great and does not appear to be affected by different operative strategies. Acute awareness and early operation appear to be the key to preventing this rare condition and its potentially drastic ramifications. Demetrios Moris, M.D. 1st Department of Surgery Athens University School of Medicine

November 2013

Vol. 79

‘‘Laikon’’ General Hospital, Athens, Greece Spiridon Vernadakis, M.D., Ph.D. Department of General, Visceral and Transplantation Surgery University Hospital Essen Essen, Germany REFERENCES

1. Kalles V, Mekras A, Mekras D, et al. De Garengeot’s hernia: a comprehensive review. Hernia 2013;17:177–82. 2. Zissin R, Brautbar O, Shapiro-Feinberg M. CT diagnosis of acute appendicitis in a femoral hernia. Br J Radiol 2000;73: 1013–4. 3. Sharma H, Jha PK, Shekhawat NS, et al. De Garengeot hernia: an analysis of our experience. Hernia 2007;11:235–8. 4. Konofaos P, Spartalis E, Smirnis A, et al. De Garengeot’s hernia in a 60-year-old woman: a case report. J Med Case Reports 2011;5:258.