Hernia (2010) 14:225–226 DOI 10.1007/s10029-010-0629-4

LE TTER TO THE EDIT OR

Appendix strangulated in a femoral hernia O. Armstrong

Received: 14 December 2009 / Accepted: 8 January 2010 / Published online: 29 January 2010 © Springer-Verlag 2010

Dear Editor, I read with interest the case report by Rajan et al. [1] reporting an “inXamed appendix in a femoral hernia sac: de Garengeot’s hernia” and referring to the paper by D’Alia et al. [2] concerning acute appendicitis in the sac of an inguinal hernia (Amyand’s hernia) and a review of the literature. I would Wrst like to congratulate Rajan et al. for their report, rare by the incidental Wnding and, moreover, occurring in a male. To complete the Fig. 1 of their case report, this paper deserves a picture for illustration. I had the opportunity to operate a case, the photo of which illustrates well the drawing of Rajan et al. (Fig. 1). A 72-year-old woman presented a small bowel obstruction according to a right strangulated femoral hernia. The examination showed a painful oval bulge in the upper root of the thigh, corresponding to the femoral canal, which was irreducible; the abdominal X-ray showed some small bowel level witnesses of the obstruction. Her laboratory Wndings were normal. She underwent an emergency surgery, by the inguinal approach, and we found a lateral stricture of a small bowel loop (Richter’s hernia) and the end of the appendix was engaged in the femoral ring, as shown in the picture. After an easy reduction (Fig. 2), an appendicectomy was performed and the parietal strangulation recovered well thanks to hot seroma and did not need resection. The femoral hole was closed by two Prolene stitches and a McVay procedure

Fig. 1 Per-operative view: appendix and small bowel incarcerated in the right femoral ring

Fig. 2 After reduction O. Armstrong (&) Clinique Chirurgicale Digestive et Endocrinienne, Hôtel Dieu, 1 Place Alexis Ricordeau, 44093 Nantes Cedex 1, France e-mail: [email protected]

was performed. The post-operative course was uneventful; she was discharged home three days later. The histological examination showed inXammatory appendicitis.

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Our case, in addition to that of Rajan et al., reports an incarceration of both appendix and small bowel. It is clear that a pelvic appendix has a higher risk of entering the femoral ring [3]. The rigid anatomical borders of this narrow ring, cranial: inguinal ligament, caudal: pectineal (Cooper) ligament and medially: lacunar (Gimbernat) ligament, show that strangulation and ischaemia quickly occur. And due to the lack of space, a lateral stricture, rather than a total parietal obstruction, is seen more often, realising a Richter’s hernia. The presence of the vermiform appendix, without complication, in the sac of an inguinal hernia is rare, reported in about 1% of cases [2, 4]. When included in a femoral sac, it is, according to the literature, more often an acute appendicitis [5, 6]. In our patient, it seems that the inXammatory process described by the histologists was only due to a mechanical stricture. But, as the patient had a clinically strangulated hernia, our behaviour was not changed: emergency surgery and the discovery of an strangulated appendix was a surprise!

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In conclusion, we agree with the interest of the case reported by Rajan et al., and our contribution has two aims: to report a new case of femoral strangulated hernia with both viscera included (appendix and lateral wall of the small bowel) and give an illustration.

References 1. Rajan SS, Girn HRS, Ainslie WG (2009) InXamed appendix in a femoral hernial sac: de Garengeot’s hernia. Hernia 13:551–553 2. D’Alia C, Lo Schiavo MG, Tonante A et al (2003) Amyand’s hernia: case report and review of the literature. Hernia 7:89–91 3. Guirguis EM, Taylor GA, Chadwick CDJ (1989) Femoral appendicitis: an unusual case. Can J Surg 32:380–381 4. Lyass S, Kim A, Bauer J (1997) Perforated appendicitis within an inguinal hernia: case report and review of the literature. Am J Gastroenterol 92(4):700–702 5. Akopian G, Alexander M (2005) De Garengeot hernia: appendicitis within a femoral hernia. Am Surg 71:526–527 6. D’Ambrosio N, Katz D, Hines J (2006) Perforated appendix within a femoral hernia. AJR Am J Roentgeol 186:906–907