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Abstract
De Garengeot hernia is a rare phenomenon describing the migration of the appendix into a femoral hernia sac. Many repair strategies have been described although an open inguinal approach with suture repair is the most common technique. Despite strong evidence that mesh limits recurrence, most forgo mesh use in the presence of appendicitis for fear of contamination. We report a case in a 68-year-old man managed completely with minimally invasive strategies. We performed a staged laparoscopic appendectomy followed by robotic hernia repair with polypropylene mesh. This is the first described two-stage minimally invasive approach and the first report demonstrating the feasibility of robotic hernia repair in the setting of de Garengeot hernia. It is our opinion that using a staged approach may encourage mesh repair by minimising the risk of implant contamination. Furthermore, we believe a fully minimally invasive technique may result in improved outcomes.
- gastrointestinal surgery
- general surgery
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Background
De Garengeot hernia was first described by 18th century surgeon, René-Jacques Croissant de Garengeot.1 The eponym describes the migration of the appendix into a femoral hernia sac. It is a rare phenomenon found incidentally in about 1% of femoral hernia cases.2 Appendicitis associated with de Garengeot hernia is more uncommon, with a reported incidence of 0.08%–0.13% of all femoral hernias.3 A recent systemic review of de Garengeot hernia found a total of 222 cases reported in the literature since the 1920s.4 A recent meta-analysis of de Garengeot hernia showed that the largest induvial series included only seven patients.5 6
There is no consensus on the optimal operative management of de Garengeot hernia. Many strategies for operative repair have been described in the literature, although an open inguinal approach with suture repair is the most common technique.5 Both a staged surgery, separating appendectomy and hernia repair, and a single operation are feasible. The use of mesh is another area of uncertainty, with many surgeons forgoing mesh use for fear of contamination. To our knowledge, there are no described cases of robotic repair. We report a case of staged repair with laparoscopic appendectomy followed by robotic hernia repair with polypropylene mesh. This case is important because it both highlights the feasibility of minimally invasive techniques in the management of de Garengeot hernia and proposes a staged strategy that encourages mesh repair.
Case presentation
A 68-year-old man presented to the emergency room with new onset right groin pain and a bulge first noticed 3 days prior. His medical history was significant for gastro-oesophageal reflux disease. On initial evaluation, he was afebrile and haemodynamically stable. His body mass index was 20 kg/m2. Bloodwork showed a white blood cell count of 10.2×109/L and lactic acid level of 0.61 mmol/L. On examination, he had a partially reducible hernia inferior to the inguinal ligament. He had mild overlying tenderness and erythema.
Investigations
A CT scan was performed, which showed a right femoral hernia, which contained the appendix along with associated fat and a small amount of fluid (figure 1). The appendix was dilated with the tip measuring up to 1 cm with mural hyperenhancement and adjacent fat strandings (figure 2).
Coronal CT scan depicting appendix within femoral hernia space. The arrow is pointing to the appendix as it enters the femoral space.
Coronal CT scan depicting fat stranding and wall thickening at the distal appendix suggestive of appendicitis. The arrow is pointing to the distal appendix within the femoral hernia sac.
Differential diagnosis
The CT scan was consistent with de Garengeot hernia as it showed the appendix within the femoral hernia defect. The diagnosis of appendicitis was made based on clinical and radiological data. The patient was afebrile with only a mild leucocytosis. Nonetheless, examination findings of pain and erythema, along with CT findings, including dilation, mural hyperenhancement and fat stranding, were suggestive of appendicitis.
Treatment
The patient was taken to the operating room on hospital day 1. His American Society of Anesthesiology Classification was 2. On initial laparoscopy, the appendix was identified protruding into a femoral hernia defect (figure 3). The appendix was gently reduced laparoscopically into the abdominal cavity. The tip of the appendix appeared dusky; however, the remainder of the appendix had no significant signs of disease (figure 4). There was no gross spillage. The mesoappendix was divided down to the base of the appendix. The appendix was then excised using a laparoscopic stapler. The patient was discharged home on the day of surgery with planned re-admission for hernia repair. He was maintained on Augmentin (875 mg, three times a day) for 4 days.
Intraoperative image during the initial laparoscopic surgery showing the appendix within the femoral space.
Intraoperative image of the appendix reduced from the femoral space during the initial laparoscopic surgery. The tip of the appendix appears to be dusky but there is no sign of perforation.
On the fourth postoperative day, he presented for elective robotic femoral hernia repair. Robotic ports were placed and the robot was docked. There was an obvious femoral hernia defect below the right inguinal ligament and medial to the femoral vessels (figure 5). Using the robot, the peritoneum over the right abdomen was incised transversely and the preperitoneal space was dissected down to the level of the inguinal ligament. There was a small fat-containing direct hernia that was gently reduced. The attenuated transversus abdominus fascia in the direct hernia space was imbricated using absorbable sutures, closing the direct space. A polypropylene mesh was placed in the preperitoneal space covering the femoral, indirect and direct spaces. The peritoneal flap was closed using absorbable sutures.
Intraoperative image of inguinal region during the robotic hernia repair.
Outcome and follow-up
The postoperative course was unremarkable and the patient was discharged the same day. The patient was doing well at the 2-week postoperative visit. His pain was well controlled and incisions were healing appropriately, with no signs of recurrence.
Discussion
De Garengeot hernia is a rare phenomenon in the spectrum of hernia disease. As such, there is no consensus on the optimal treatment strategy. According to a recent meta-analysis, a single-stage open inguinal approach with suture repair is by far the most common repair method. Various case reports have described complete laparoscopic approaches as well as hybrid laparoscopic/open techniques.7–12
There are few case reports on minimally invasive surgery for the treatment of de Garengeot hernia. Sibona et al and Thomas et al described cases of concomitant appendicitis in which laparoscopic appendectomy was followed by open femoral hernia repair without the use of mesh.10 11 Ramsingh et al presented an identical approach; however, they did use a mesh plug noting the appendix appeared normal with no inflammatory changes.12
Fully minimally invasive laparoscopic approaches have been published using totally extraperitoneal (TEP) and transabdominal extraperitoneal (TAPP) repair. Al-subaie et al described a single-stage repair with mesh in a 59-year-old woman with a non-inflamed appendix.7 Comman et al described a similar repair in a 28-year-old woman.8 Beysens et al described a laparoscopic appendectomy followed by a TEP repair with mesh in a single-stage approach. The appendix in this case did show signs of strangulation. The authors argued about the advantage of TEP compared with TAPP repair in placing the mesh outside the contaminated field.9
Notably, all the aforementioned minimally invasive techniques used a single-stage approach. To our knowledge, this is the first described two-stage minimally invasive strategy for the treatment of de Garengeot hernia. Moreover, it is the first report demonstrating the feasibility of robotic hernia repair.
It is well validated that the use of mesh limits recurrence after inguinal hernia repair with a relative reduction of about 30%–50%.13 However, most authors forgo the use of mesh placement in the presence of appendicitis. There are 59 cases of de Garengeot hernia published where mesh was not used during hernia repair. Fifty-five of these cases showed signs of appendiceal inflammation.5 Echoing the sentiment of Beysens et al, we agree that using a single-stage TAPP approach with permanent mesh, especially in cases where there is concern for contamination, may be problematic.
We propose using a staged repair in the setting of presumed inflammation of the appendix to ensure safe mesh placement and minimize subsequent recurrence rates. Specifically, the staged approach allowed for a short course of antibiotic therapy and provided a second opportunity to visually re-evaluate the surgical field. Although antibiotics are not generally necessary postoperatively for uncomplicated appendicitis, we used a short course of oral antibiotics to ensure a clean operative field in case there was residual occult infection. The 4-day cut-off is well validated for the successful treatment intra-abdominal infections after source control.14 It should be noted that there are drawbacks to a staged repair—namely, the short-term cost and added morbidity of a second operation. We believe these drawbacks pale in comparison to the cost and morbidity that would result from a hernia recurrence or mesh infection.
Despite our use of a staged approach, we suppose there remained a theoretical risk of mesh infection. Classic teaching is to avoid mesh placement in emergent or contaminated fields. However, this dogma has evolved over the last decade. Recent studies have validated the safety of using mesh in clean-contaminated fields, with some studies even suggesting its safety in contaminated fields.15–18 These repairs have been associated with lower recurrence rates without the expense of significant wound infection rates.15 17 18 Considering our staged robotic repair was in a clean surgical field, 4 days after the initial insult and a course of antibiotics, we believe the risk of contamination was minimal and did not preclude mesh placement.
This case also demonstrated the feasibility of a robotic approach to femoral hernia repair in the setting of de Garengeot hernia. A few studies on robotic hernia repair have shown several advantages compared with laparoscopic repair, including fewer complications and less postoperative pain.19–21 However, recent prospective data suggests no difference in outcomes between robotic and laparoscopic hernia repair, although in ‘straightforward’ inguinal hernia cases.22 The best approach in complex and recurrent hernia cases is unclear and may be benefited by the robotic platform, which theoretically offers better visualisation, improved ergonomics, reduced tremor and wristed movements.22 Other surgical subspecialties have reported improved outcomes using the robotic platform, particularly in complex cases.23–25
It is our opinion that, with adequate surgeon experience, outcomes are likely identical between laparoscopic and robotic surgeries, especially in routine cases. We chose to perform this case robotically because the operating surgeon was experienced and adept on the robotic platform and there was added complexity in the setting of recent appendicitis. We do think other minimally invasive strategies, including TEP and TAPP repair, would be appropriate. As mentioned, TEP repair has the theoretical benefit of a clean surgical plane. Nonetheless, a robotic approach should be considered in more complex cases if surgeon expertise allows it. Overall, we advise that surgeon experience should be the guiding principle in choosing a minimally invasive approach.
Compared with open repair, we do prefer a completely minimally invasive strategy for appendectomy and femoral hernia repair. Studies comparing minimally invasive hernia repair to conventional open techniques have demonstrated less persisting pain and numbness, faster return to activities, lower infection rate, shorter length of stay and lower 30-day readmission rates associated with a minimally invasive approach.13 19
Patient’s perspective
I believe it was a good call on (the surgical team’s) part when (they were) feeling around the hernia and said something didn’t feel ‘right’ and ordered the scan, which discovered that the appendix had migrated into the femoral hernia sac…we could have had an ugly situation.
Learning points
De Garengeot hernia is a rare phenomenon in the spectrum of hernia disease and the optimal strategy for repair is unclear.
Using a staged approach may encourage mesh repair and minimize the risk of hernia recurrence and of implant contamination.
Although a robotic approach may theoretically be beneficial in complex cases, the minimally invasive strategy should be guided by surgeon experience.
A fully minimally invasive strategy, whether robotic or laparoscopic, may result in improved outcomes.
Ethics statements
References
Footnotes
Twitter @ryancohenmd
Contributors All authors listed have contributed significantly to the manuscript. RC, MH and TN contributed to the planning, conduct and reporting of the article. SW contributed to the planning and conduct of the article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer-reviewed.