De Garengeot hernia with acute appendicitis as an incidental finding during right hemicolectomy for transverse colon tumor: a case report

De Garengeot hernia is an uncommon variant of femoral hernia in which the hernial sac contains the vermiform appendix. Due to its low frequency, the available evidence comes from case reports and small series, and the diagnosis is usually established during surgery rather than in the preoperative period. Even with imaging studies, preoperative confirmation is reported in a minority of cases, which reaffirms its diagnostic challenge.

Beyond its rarity, this entity is of surgical interest due to the therapeutic implications it poses when associated with appendiceal inflammation. In the case presented, the finding occurred in the context of a right hemicolectomy for a stenosing transverse colon tumor. While it could be hypothesized that colonic obstruction with proximal dilatation and a sustained increase in intra-abdominal pressure might theoretically favor the herniation of the appendix and its incarceration in the femoral canal, this pathophysiological mechanism remains speculative and should be interpreted with caution as a potential contributing factor rather than a confirmed cause. In this sense, the association should not be interpreted solely as an incidental finding, but rather as an anatomical and functional interaction with direct surgical repercussions.

A 45-year-old male patient presented to the Department of General Surgery at Hospital Angeles Querétaro in Querétaro, Mexico, with chronic abdominal discomfort associated with nausea and vomiting. He had previously been evaluated by other physicians, who attributed his symptoms to irritable bowel syndrome; however, no clinical improvement was observed. He denied fever, weight loss, or other systemic symptoms. On physical examination, the patient was hemodynamically stable and afebrile, with mild tachycardia (heart rate, 99 beats/min). Abdominal examination revealed no signs of peritoneal irritation, guarding, or rebound tenderness. There was no localized abdominal tenderness in any specific quadrant, including the right lower quadrant, and no tenderness at McBurney’s point or other clinical findings suggestive of acute appendicitis. Because the patient had no groin-related symptoms or clinical suspicion of groin pathology, a targeted preoperative groin examination was not documented. No groin mass or tenderness had been reported by the patient before surgery.

Preoperative laboratory studies showed mild leukocytosis, with a white blood cell count of 12,000/µL and 80% neutrophils, which was interpreted as a nonspecific inflammatory response. C-reactive protein (CRP) and other specific inflammatory markers were not available in the medical record. No other significant laboratory abnormalities were identified. As part of the diagnostic workup, an abdominal computed tomography scan was performed and revealed a stenosing tumor of the transverse colon without other relevant abnormalities. Notably, the associated femoral hernia and appendiceal involvement were not identified preoperatively and were only recognized as incidental intraoperative findings (Fig. 1). Based on the radiological findings, laparoscopic surgical management was scheduled. A right hemicolectomy was performed for the stenosing transverse colon tumor.

During the surgical procedure, a right-sided De Garengeot hernia was incidentally identified, associated with hyperemic and edematous acute appendicitis; the base was preserved, non-perforated, and without abscess formation along its path, a finding not identified in preoperative imaging studies (Fig. 2). Due to severe adhesions and inflammation of the appendix within the femoral hernial defect, it was not resected en bloc with the right hemicolectomy specimen. Instead, the appendiceal base was secured and closed with a Hem-o-lok clip to ensure proper control; subsequently, the appendix was cut at its preserved base using scissors. Following this, gentle blunt dissection with gauzes and the use of a LigaSure device were performed to release the surrounding tissues, facilitating the reduction and complete extraction of the appendix from the hernial defect. Following extraction of the appendix, a tension-bearing hernioplasty of the femoral defect was performed using a continuous barbed suture without prosthetic mesh. Repair of the femoral defect was achieved by approximating the tissues with tension using the continuous barbed suture. The finding did not modify the planned oncological resection but required simultaneous resolution of the hernia during the same surgical session.

Microscopic examination of the appendiceal specimen revealed findings consistent with acute non-suppurative appendicitis. There was marked infiltration of acute inflammatory cells, predominantly neutrophils, scattered throughout the lamina propria and involving the surface and crypt epithelium, with evidence of cryptitis. The inflammatory infiltrate extended into the submucosa; however, the muscularis propria and serosa were spared from extensive transmural inflammation, with no evidence of massive suppuration, tissue necrosis, gangrene, or perforation. Additionally, prominent reactive lymphoid hyperplasia was identified within the submucosal follicles, alongside vascular congestion and mild edema in the mesoappendix, with no diffuse purulent exudate on the serosal surface. These findings confirmed an acute inflammatory process of a non-suppurative nature, as neutrophil infiltration was limited to the mucosa and superficial submucosa, without the deep mural abscesses or extensive transmural destruction characteristic of the suppurative variant.

The definitive histopathological study of the resected colonic specimen confirmed a moderately differentiated, stenosing transverse colon adenocarcinoma with invasion up to the subserosa, consistent with pT3. Sixteen lymph nodes were examined, all negative for metastasis, resulting in a nodal status of pN0. Consequently, the pathological stage corresponded to stage IIA (pT3N0M0). The postoperative period was uneventful, and the patient was discharged on the fifth postoperative day. Follow-up by our team was performed at one week and one month after discharge, during which the patient presented no complications and no evidence of hernia recurrence. Following completion of routine postoperative follow-up by the General Surgery service, the patient was referred to the Oncology service and continued his oncological care and long-term follow-up through private medical services. Consequently, information regarding his subsequent oncological course was no longer available to our surgical team.

Due to its low frequency, the available evidence regarding De Garengeot hernia comes primarily from case reports and small series. Consequently, the preoperative diagnosis remains a challenge, being achieved in only 14–31.5% of patients, which reflects both the rarity of the entity and the non-specificity of its clinical presentation [1,2]. Femoral hernias account for approximately 3–4% of all groin hernias; among these, De Garengeot hernia constitutes only 0.5–1%, while the presence of acute appendicitis within the hernial sac is even more infrequent, with an estimated incidence of 0.08–0.13% [3]. It should be noted that there is a risk of incarceration of up to 56% in this entity, conditioned by the narrowness of the femoral canal [4].

Published series also demonstrate a marked predominance among elderly women. In the systematic review by Guenther et al., 81.1% of patients were female, with a mean age at presentation of approximately 70 years. Similarly, Linder et al. reported a strong female predominance, with women accounting for approximately 83% of their cohort and median ages of 73 and 78 years among women and men, respectively [5,6]. Therefore, presentation in a 45-year-old male, as occurred in the present case, represents a distinctly atypical demographic profile.

Preoperative recognition remains one of the main diagnostic challenges associated with De Garengeot hernia. Computed tomography is currently the most useful imaging modality, although its diagnostic performance remains limited. Guenther et al. reported that only 31.5% of 222 cases were correctly diagnosed before surgery, with a CT sensitivity of approximately 61% [5]. Similarly, Linder et al. reported a correct CT diagnosis in 23 of 34 patients, while Gómez-Portilla et al. described a CT sensitivity of approximately 70% among patients managed through a fully laparoscopic approach [6,7]. When recognized radiologically, De Garengeot hernia may appear as a blind-ending tubular structure extending from the cecal region into the femoral canal, with associated surrounding fluid or inflammatory changes. Coronal and sagittal reconstructions may further facilitate identification of the relationship between the appendix, cecum, and femoral hernia sac [7,8]. Thus, even when cross-sectional imaging is available, De Garengeot hernia may remain unrecognized or may be misclassified as another type of groin hernia [9].

Most described cases present as a painful, irreducible femoral mass located below and lateral to the pubic tubercle, a finding useful for differentiating it from an inguinal hernia, which is usually located in a superomedial position [10,11]. In the systematic review by Guenther et al., a groin bulge and groin tenderness were observed on physical examination in 95.0% and 86.5% of patients, respectively. In contrast, abdominal pain occurred in only 22.5% of cases and abdominal tenderness in 13.5% [5]. Likewise, confinement of the inflammatory process within the femoral ring limits the spread of inflammation; therefore, manifestations such as diffuse abdominal pain, peritonitis, or systemic signs of sepsis are less frequent than in conventional appendicitis [10]. The narrow and relatively non-compliant femoral canal may isolate the inflammatory process from the abdominal cavity, explaining why classical manifestations of appendicitis and signs of peritoneal irritation may be absent despite significant appendiceal involvement [5,7].

The pathophysiological mechanism by which the appendix enters the femoral canal remains incompletely understood. Several anatomical factors have been proposed, including a low-lying cecum associated with intestinal malrotation, increased cecal mobility, and an unusually long appendix, all of which may facilitate migration of the appendix toward the femoral ring. Once entrapped, repetitive mechanical trauma may promote adhesion formation and persistent incarceration. Furthermore, compression at the rigid femoral ring may impair venous drainage and appendiceal perfusion, producing congestion, ischemia, and subsequent inflammation. Therefore, appendicitis in De Garengeot hernia may develop secondary to extraluminal mechanical compression rather than through the intraluminal obstruction usually implicated in conventional acute appendicitis [5].

This mechanism is particularly relevant to the present case. Despite appendiceal involvement within the femoral hernia, the patient had no signs of peritoneal irritation, no localized tenderness in the right lower quadrant, and no tenderness at McBurney’s point. He remained afebrile and presented only mild leukocytosis, with a white blood cell count of 12,000/µL and 80% neutrophils. No targeted preoperative groin examination was documented because there were no groin-related symptoms or clinical suspicion of groin pathology, and no groin mass or tenderness had been reported by the patient. The simultaneous presence of a stenosing transverse colon adenocarcinoma meant that diagnostic attention was focused primarily on the oncological pathology, which likely contributed to the hernia not being suspected before surgery. This scenario highlights how a predominant abdominal disease can hinder recognition of a rare concomitant condition.

Although preoperative abdominal CT had been performed, neither the femoral hernia nor the appendiceal involvement was initially recognized. Considering that published series report CT sensitivities ranging approximately from 61% to 70%, failure to identify the condition preoperatively is consistent with the diagnostic limitations described in the literature rather than being an exceptional occurrence [5-7]. In the present patient, the absence of groin-related symptoms and of classical clinical findings of appendicitis likely further reduced both clinical and radiological suspicion.

The surgical management of De Garengeot hernia continues to be a subject of debate and must be individualized according to intraoperative findings, the condition of the appendix, and the degree of contamination of the surgical field [12,13]. Historically, open groin exploration has been the most frequently reported approach, allowing direct evaluation of the hernia sac, reduction of its contents, appendectomy when required, and simultaneous repair of the femoral defect [5,6,12,13]. When the appendiceal base can be safely exposed through the groin incision, appendectomy may be performed without additional abdominal access. However, inadequate exposure of the appendiceal base, uncertainty regarding complete reduction, associated bowel involvement, or the need to evaluate additional intra-abdominal pathology may require laparotomy, laparoscopy, or a combined approach [5,8,12,13].

Although appendectomy is usually part of the treatment when appendiceal inflammation exists, some authors have proposed preserving a macroscopically normal appendix in selected situations. Guenther et al. reported appendectomy in 98.5% of cases and suggested its performance whenever the appendix appears macroscopically abnormal [5]. Nevertheless, Gómez-Portilla et al. described successful appendix-preserving management in selected laparoscopically treated patients in whom the appendix appeared viable after reduction, indicating that routine removal may not be mandatory when appendiceal viability is clearly preserved [7].

Likewise, the laparoscopic approach has emerged as a useful alternative when the diagnosis is unclear, as it permits exploration of the abdominal cavity and facilitates intraoperative decision-making. Both transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques have been reported. In the systematic review by Gómez-Portilla et al., 25 of 29 patients managed entirely laparoscopically underwent TAPP, whereas four underwent TEP [7]. The transabdominal approach offers the advantage of direct inspection of the appendix and cecum, controlled reduction of the hernia contents, performance of appendectomy when necessary, and repair of the femoral defect during the same procedure. In addition, it allows systematic examination of the remainder of the abdominal cavity, which is particularly advantageous when associated intra-abdominal pathology is present [5,7]. In that review, the median hospital stay was 2.5 days and no postoperative complications were reported among patients with available outcome information, although these findings should be interpreted cautiously because of the limited number and selected nature of the published cases [7].

The use of prosthetic mesh is another controversial aspect of treatment. Mesh repair may be considered when the appendix is viable and contamination of the operative field is minimal, particularly because prosthetic repair may reduce the risk of hernia recurrence. Conversely, significant inflammation, abscess formation, perforation, or gross contamination generally favors primary tissue repair because of the potential risk of prosthetic infection [5,6,8,9,12,13]. In the meta-analysis by Linder et al., no patient with appendiceal perforation underwent mesh or plug placement, supporting a cautious approach to prosthetic material in contaminated fields [6]. Primary suture repair without prosthetic material has also been successfully described in individual cases of De Garengeot hernia with an inflamed appendix [9,13]. Nevertheless, mesh has been successfully employed in selected patients without perforation, suggesting that the decision should be based primarily on the intraoperative degree of contamination rather than on the diagnosis of De Garengeot hernia alone.

In the present case, the coexistence of a De Garengeot hernia with acute appendicitis required treatment of both the appendiceal and hernia-related pathology during the same surgical session. Given the inflammatory findings, the femoral defect was treated by primary suture repair using a continuous barbed suture without prosthetic mesh. The laparoscopic approach allowed identification of an unsuspected pathology while simultaneously completing the planned oncological resection and managing the femoral defect. This case therefore illustrates the broad clinical spectrum of De Garengeot hernia and emphasizes the value of systematic intra-abdominal exploration, particularly when unexpected findings arise during surgery for an unrelated abdominal condition.

The significance of this case does not lie solely in the coexistence of two infrequent entities, but rather in the implications this association had for surgical decision-making. The intraoperative identification of a De Garengeot hernia with non-suppurative appendicitis required the simultaneous treatment of acute appendicitis and a potentially curable colon adenocarcinoma. This scenario, sparsely described in the literature, highlights the importance of systematic exploration during surgery and of adapting the surgical strategy to unexpected intraoperative findings, particularly when pathologies of a different nature coexist and require treatment during the same surgical session.