Season 8 Case 37

Hx: abdominal pain. Palpable mass.

Season 8 Case 37

History: Abdominal Pain, Palpable mass













Answer: De Garengeot Hernia with acute appendicitis!

A De Garengeot hernia is a femoral hernia containing the appendix, which is exactly what we have here but the appendix is hyperenhancing with wall thickening and surrounding fluid consistent with acute appendicitis.

Named after a French surgeon from the 1700s, these are fairly rare (<3% of femoral hernias), with complicating appendicitis even more rare.

Understanding groin hernias can take time and they are not always easy to figure out. There are 2 major types:

Inguinal hernia

~80% of abdominal wall hernias

MLF ratio of 7:1

Types:

1) Indirect 

-more common

-Can be a)congenital defect in a patent process vaginalis in young males or b) acquired do to stretching/weakness of the inguinal ring in older patients

- passes through deep inguinal ring 

- LATERAL to the inferior epigastric artery

- anterior to spermatic cord or may insinuate around the inguinal contents

2) Direct

- less common

- secondary to weakness in floor of inguinal canal (Hesselbach’s triangle)

- MEDIAL to inferior epigastric artery (therefore inguinal contents generally displaced laterally)

Image below shows the inferior epigastric vessels labeled as Orange so the fat lateral to the vessels would be the INDIRECT hernia (blue) and the fat medial the the vessels (red) would be the DIRECT hernia.But both go into the inguinal canal, just through different routes.

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A femoral hernia is a hernia through the femoral ring, so it is inferior to inguinal ligament and lateral to the inguinal canal. As it protrudes through the femoral ring, it can compress the normal femoral canal contents, primarily the femoral vein. You tend to see it seeing more on top of the pectineus muscle as it lies on the superior pubic ramus.

Here we see a small fat containing femoral hernia (yellow) compared to a normal inguinal canal (blue)

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Groin hernia summary: Inguinal hernia extend inf and medial into inguinal canal. Direct take a “direct course” medial to inf epigastric artery vs Indirect go more “indirectly” lateral to vessels Femoral hernias go inf and lateral through femoral ring compressing the femoral vein. 

“Fancy” Groin hernias: 

 Amyand hernia = inguinal hernia containing appendix (some say specifically appendicitis) 

 De Garengeot hernia = femoral hernia containing appendix (or appendicitis as we see here!) 

Here we have a De Garengeot Hernia. Labels: Hernia yellow, appendix red 

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