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Journal of Surgery & Transplantation Science

Cite this article: Páramo AA, García EP, Menchen B, Bertelli JL, Núñez P, et al. (2016) De Garengeot Hernia: A Report of 3 Cases and Bibliographic Review. J Surg Transplant Sci 4(2): 1026.

*Corresponding authorAna Alberca Páramo, Service General Surgery and Digestive Diseases C/ Forsaken, 50. Aguilar de la Frontera, Cordoba, Spain, Tel: 926-278000; Email:

Submitted: 20 February 2016

Accepted: 06 March 2016

Published: 02 April 2016

ISSN: 2379-0911

Copyright© 2016 Páramo et al.

OPEN ACCESS

Keywords•Hernia•De Garengeot•Amyand

Review Article

De Garengeot Hernia: A Report of 3 Cases and Bibliographic ReviewAna Alberca Páramo1*, García EP1, Menchen B1, Bertelli JL1, Núñez P1 and Suazo I2

1Service General Surgery and Digestive Diseases, Hospital General Universitario de Ciudad Real, Spain 2Service Angiology and Vascular Surgery, General Hospital Miguel Servet, Spain

Abstract

Introduction: Amyand’s hernia is an indirect inguinal hernia, whose content is an inflamed or non cecal appendix.

Presentation of cases: We present three cases found in 2015 at the General University Hospital of Ciudad Real. The average age was 71 years, all referred inguinal mass; only one of them had an episode of incarceration, which was resolved conservatively. Programmed surgery was performed with inguinal region repair using prosthetic material and reduction of ileocecal appendix. No postoperative complications or recurrences were observed.

Discussion: The inguinal hernia is a visceral or tissue protrusion, typically the omentum, through an orifice or anatomical defect. Amyand described first apendicectomy in indirect inguinal hernias with inflamed cecal appendix within the peritoneal sac in 1735.

Preoperative diagnosis is difficult and it is based on clinical information and physical examination (diffuse abdominal pain, lump in inguinal region). Even the use of complementary tests could not give us the pertinent information. The treatment with appendicular dissection and inguinal region repair with or without prosthesis depends on the inflammatory state of the ileocecal appendix. Some authors recommend the use of laparoscopy.

Conclusions: This pathology has a very low frequency. Treatment consists of reducing it without excision, with repair of inguinal region with prosthetic material, although, laparoscopy may be useful.

ABBREVIATIONSCOPD: Chronic Obstructive Pulmonary Disease

INTRODUCTIONThe presence of the appendix vermiformis inflamed or non

inflamed within an indirect inguinal hernia sac is uncommon and they have an incidence about 0.1% and they called Amyand’s hernia [1,2]. The incidence of appendicitis inside the hernia sac comprises 0.9 -1.7% of all cases of appendicitis [3].

De Garengeot hernia is an femoral hernia, whose content is an inflamed or non- inflamed cecal appendix [4,5]. First described by this author, in 1731 [4].They have an incidence of 0.9% [1,6]. Appendicitis as femoral hernia sac content have an ever lower incidence, ranging from 0.13- 08% [7].

CASE PRESENTATION We present a series of cases objectified in the programmed

surgical interventions at the General University Hospital of Ciudad Real from January 1st, 2015 to December 31st, 2015.

Case 1

A 72 years-old, male, with clinical background of lithiasis, COPD in treatment and left inguinal hernia repair. The patient consulted to Surgery consultation with a 2- year history of right inguinal mass, with an episode of incarceration solved conservatively by maneuvers of taxis. Surgery was programmed for 6 months later.

A hernia through the inguinal canal was found during the examination maneuvers of the inguinal region, which was

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easily reducible. During the surgery, content was found inside the hernia sac, which was decided to open, observing the cecal appendix with no signs of complications (Figure 1). After closing and reducing the hernia sac, reconstruction was performed using the Rutkow – Robbins technique.

Case 2

A 64 years-old male, surgically treated for bladder cancer 7 years ago and right hip fracture. The patient was referred to Surgery consultation with a 20-year history of an asymptomatic right inguinal mass.

An indirect, voluminous right hernia was found during the examination maneuvers of the inguinal region, with no signs of incarceration, but was non-reducible. With these findings, a programmed surgical reduction was performed. During the surgery, opening of the hernia sac was made due to the presence of a mass of unknown origin. A non-inflamed iliocecal appendix was found inside, therefore, it was reduced into the abdominal cavity. The reconstruction was performed using the Rutkow – Robbins technique.

Case 3

A 77 years-old male, with no clinical background, consulted the General surgery consults with a 4 month history of right inguinal region mass. A right inguinal hernia with no vascular compromise was found during the physical examination maneuvers. A programmed surgery was performed, observing inside the hernia sac a non-inflamed ileocecal appendix (Figure 2). Inguinal region repair was made with the Rutkow-Robbins technique.

DISCUSSION The inguinal hernia is a visceral or tissue protrusion, typically

the omentum, through an orifice or anatomical defect [8]. The usual content of the hernia sac is the omentum or small intestine, nevertheless, in rare occasions we may find bladder, Meckel’s diverticulum (Littré hernia), or ileocecal appendix [8]. A French surgeon, Rene Jacques Croissant de Garengeot, first described in 1731 the non-inflamed cecal appendix inside the peritoneal sac of an inguinofemoral hernia. Therefore, this type of hernia receives the name of De Garengeot hernia [9].

These types of hernias are more frequently in womens and it is associated to congenital defects [10].

In 1735, Claudius Amyand performed the first appendectomy in children with perforated appendix inside the incarcerated inguinal hernia sac. This type of hernia is called Amyand hernia [11]. Amyand’s hernia is more common in men; the average age of this patient is 42 years, although there are also pediatric cases [12]. It occurs most frequently on the right side, left hernias are associated to situs inversus, mobile cecum, malrotation of intestine, and excessively long appendix [13]. In the literature these terms are often confused, the principal difference is the protrusion site. The pathogenesis of this type of hernia is unclear. Several theories exist to explain this situation, which could be due to the existence of an abnormal union because of appendix malrotation with the cecum, an abnormal cecal length or greater cecal mobility, that would cause an appendicular pelvic location with high risk of introducing into the hernia sac [1,14]. Preoperative diagnosis is difficult to make since it is a diagnosis usually based on physical examination and clinical history [9]. Diffuse abdominal pain, inguinal region lump [11], even episodes of incarceration, is usually found. They are presented as an inguinal or femoral hernia. Sometimes they attend to the emergency with a suspected clinical diagnosis of hernia incarceration, and observing during the surgery an Amyand hernia (appendicitis in the hernia sac that may even present perforation) [15]. The diagnosis by laboratory tests is difficult, even using computed tomography [16]. Although, if preoperative diagnosis is made, it may allow us to plan the therapeutic approach, especially in cases of hernia incarceration or Amyand hernias [17].

Losanoff and Basson created a classifications of Amyand’s hernia in function of their experience and described to therapeutic management: type 1 with a normal appendix; type 2 with acute appendicitis without abdominal sepsis; type 3 with acute appendicitis associated to abdominal sepsis and type 4 with acute appendicitis within inguinal hernia and another abdominal pathology associated as apendicular mucocele, adenocarcinoma or apendicular pseudomyxoma [18]. The treatment in this type of pathology is determined by the inflammatory condition in which the ileocecal appendix is found. If we are dealing with non-inflamed ileocecal appendix, appendix reduction without making appendectomy and the placement of prosthetic material in the inguinal region is recommended to repair the inguinal defect

[19]. Other authors, however, indicate that even presenting no signs of inflammation, a standard appendectomy should be performed; this is based on the inability to discard a microscopic inflammation caused by compression and ischemia in the hernia neck [20]. If we find appendicitis inside the hernia sac, that is,

Figure 1 Open the hernia sac and observing the cecal appendix with no signs of complications.

Figure 2 The cecal appendix without signs of complications content inside the hernia sac.

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an Amyand hernia, the treatment is appendectomy and repair of the inguinal region with suture and it is not recommended with prosthetic material because of the high risk of developing an infection, since it is a contaminated area [21].

The use of prosthetic material reduces the risk of recurrence, but in cases with infection or inflammation of the hernia content this treatment is not recommended [22]. Although, we found in some reviews articles, the use of prosthetic material without development of surgical site infection [1]. In our cases the average age of our patients was 71 years, all with a history of inguinal mass of months or years of evolution. Only one of them had a previous episode of incarceration, which was resolved conservatively (Table 1). Programmed surgery was performed to the three cases, with inguinal region repair (using prosthetic material) and reduction of ileocecal appendix, by the Ruthow-Robbins technique.We make no appendicectomy because we observed a normal appendicite vermiformis, as no macroscopic inflammation signs, as recommended Losanoff and Basson in his study [18]. According to these authors to perform an appendectomy in these cases become a surgery to clean priori in a clean-contaminated surgery, which contraindicate the inguinal region with prosthetic material [18,26]. Others authors recommend appendectomy to avoid future complications, above all if the pediatric casescan develop future appendicitis that present at the time of diagnosis microscopic appendicitis and therefore not objectified macroscopic inflammation [23,24].

The hospital discharge was performed after six hours of surgery, according to the criteria of Ambulatory Major Surgery of our center. No late postoperative complications or recurrences were observed in any case.

Some authors state that the use of laparoscopy in hernia pathology could be useful in these situations to evaluate possible incarcerations, hernia reduction and intestinal resection in case of complications [25-27].

CONCLUSIONDe Garengeot hernias present a very low frequency, few

series of cases exist. The treatment of this type of hernia consists in reducing it without excision with inguinal region repair with prosthetic material. Nevertheless, laparoscopy may also allow us to decide and act in these situations. Even with a low incidence, it is important to have them in consideration during hernia repairs.

ACKNOWLEDGEMENTSThe author wish to thank Dr. Suazo and Landa for their help

in this report.

REFERENCES 1. Adriana Hernández López, Alberto Mitsuo León Takahashi, Adrián

Murillo Zolezzi. Garengeot herniation. Case report and literature review. Surgeon General. 2012; 34: 1.

2. Creese PG. The first appendectomy. Surg Gynecol Obstet. 1953; 97: 643-652.

3. Ivanschuk G, Cesmebasi A, Sorenson EP, Blaak C, Loukas M, Tubbs SR. Amyand’s hernia: a review. Med Sci Monit. 2014; 20: 140-146.

4. Ortega Leon L.H, Ramirez Tapia D, Dieguez - Jimenez C.M, Cruz Melgar L.M; García Puig M.A, Chavez Gomez A, et al. Amyand Hernia : A case report and review of the literature. Rev Med Hosp Gen Mex 2011; 74: 98-100.

5. Cordova A, Viscido G, Picon Molina H, Palencia R, Doniquian A. Hernia Amyand: communication of two cases repaired Rutkow -Robbins technique. Rev hispanoam hernia. 2014; 2: 111-114.

6. Thomas WE, Vowles KD, Williamson RC. Appendicitis in external herniae. Ann R Coll Surg Engl. 1982; 64: 121-122.

7. Adriana Hernandez Lopez, Alberto Mitsuo Takahashi Leon, Adrian Murillo Zolezzi. Review Of Garengeot hernia. A case report and literature review. Cir Gen. 2012; 34.

8. Deysine M. Hernia clinic in a teaching institution: creation and development. Hernia. 2001; 5: 65-69.

9. Arce Aranda C, Rojas R, Lopez L, Correa M, Sanchez R, Soskin Reidman A cecal. appendix in the hernia sac: Hernia Hernia vs Garengeot Amyand. Presentation of clinical cases. An Fac Cienc Phys. (Asuncion) 2009; 1.

10. Shah A, Sira janardhan H. De Garengeot Hernia: A Case Report and Review of Literature. Indian J Surg. 2013; 75: 439–441.

11. Hutchinson R. Amyand’s hernia. J R Soc Med. 1993; 86: 104-105.

12. Milanchi S, Allins AD. Amyand’s hernia: history, imaging, and management. Hernia. 2008; 12: 321-322.

13. De la Peña López J, Silgado Kerguelen, R, Calderón Morón H. Amyand´S Hernia Presenting As An Acute Abdomen. Rev cienc biomed. 2011; 2: 106-110.

14. Sharma H, Jha PK, Shekhawat NS, Memon B, Memon MA. De Garengeot hernia: an analysis of our experience. Hernia. 2007; 11: 235-238.

15. Voitk AJ, MacFarlane JK, Estrada RL. Ruptured appendicitis in femoral hernias: report of two cases and review of the literature. Ann Surg. 1974; 179: 24-26.

16. Aashish S, Haridarshan S. De Garengeot Hernia: A Case Report and Review of Literature. Indian J Surg. 2013; 75: 439–441.

17. Talini C, Oliveira LO, Araújo AC, Netto FA, Westphalen AP. De Garengeot hernia: Case report and review. Int J Surg Case Rep. 2015; 8C: 35-37.

18. Losanoff JE, Basson MD. Amyand hernia: a classification to improve management. Hernia. 2008; 12: 325-326.

19. Isaacs LE, Felsenstein CH. Acute appendicitis in a femoral hernia: an unusual presentation of a groin mass. J Emerg Med. 2002; 23: 15-18.

20. Contreras RVR, García LRJA, González AJM, Rojas DO, Acevedo ERI, Murillo ZA. Hernia Amyand the left side: literature review and case report. Rev Esp Med Kir. 2008; 13: 88-92.

21. el Mansari O, Sakit F, Janati MI. [Acute appendicitis on crural hernia]. Presse Med. 2002; 31: 1129-1130.

22. Jorge Sancho Muriel, Antonio Torregrosa Gallud, Providencia García Pastor, Maria Lopez Rubio, Brenda G. Arguelles, Jose Bueno Lledo. Amyand herniation: report of three cases and literature review. Hernia Hispanoamericana magazine. 2015; 05: 001.

Table 1:

Patient Age Clinical Hernia

1 72 Inguinal mass Left

2 64 Asymptomatic Right

3 77 Inguinal mass Right

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Páramo AA, García EP, Menchen B, Bertelli JL, Núñez P, et al. (2016) De Garengeot Hernia: A Report of 3 Cases and Bibliographic Review. J Surg Transplant Sci 4(2): 1026.

Cite this article

23. Aguirre Etxabe L, Prieto Calvo M, García Etxebarría A, GarcíaGonzález JM, ,Sarriugarte Aingeru Lasarte, Alberto Colina Alonsoa. Amyand’s hernia (Losanoff’s type 2) preoperatively diagnosed and treated with hernioplasty with biological mesh. Hispanic Magazine Hernia. 2014; 2: 162–72.

24. Carbonell-Tatay F. Hernia inguinocrural. Valencia: Ethicon; 2001.

25. Lin E, Wear K, Tiszenkel HI. Planned reduction of incarcerated groin

hernias with hernia sac laparoscopy. Surg Endosc. 2002; 16: 936-938.

26. Thomas B, Thomas M, McVay B, Chivate J. De Garengeot hernia. JSLS. 2009; 13: 455-457.

27. Comman A, Gaetzschmann P, Hanner T, Behrend M. DeGarengeot hernia: transabdominal preperitoneal hernia repair and appendectomy. JSLS. 2007; 11: 496-501.