Case Report

A 67-year-old female was referred from a rural clinic to the emergency department of a district hospital in the Eastern Cape Province with a 3-day history of a painful right groin swelling associated with nausea and vomiting for 24 hours. She had no previous abdominal surgery, no known comorbidities, and was not on any chronic medication. She lived alone and had delayed seeking medical attention due to transport difficulties.

On examination, she was febrile (38.4°C), tachycardic (102 beats per minute), and normotensive (138/82 mmHg). Abdominal examination revealed a soft abdomen with mild right iliac fossa tenderness but no peritonism. A tender, irreducible, 4 × 3 cm mass was palpable in the right groin, located inferior and lateral to the pubic tubercle, consistent with a femoral hernia. There was overlying erythema and warmth.

Laboratory investigations revealed a leucocytosis (white cell count 14.2 × 10⁹/L) with neutrophilia, elevated C-reactive protein (186 mg/L), and normal renal function (creatinine 98 µmol/L). Given the clinical findings of an incarcerated femoral hernia with features of strangulation, computed tomography (CT) of the abdomen and pelvis was performed to evaluate the hernia contents and exclude complications.

CT imaging demonstrated a right femoral hernia containing a tubular structure arising from the caecum, consistent with the vermiform appendix (Figure 1). The appendix showed wall thickening and peri-appendiceal fat stranding, suggestive of acute appendicitis within the hernia sac (Figure 2). There was no free intraperitoneal fluid or evidence of perforation.

The patient was resuscitated with intravenous fluids and commenced on empirical broad-spectrum antibiotics (piperacillin-tazobactam). Emergency surgery was performed via an infrainguinal (Lockwood) approach to the right femoral canal.

Intraoperative findings confirmed an incarcerated femoral hernia containing the vermiform appendix. The appendix was gangrenous with a localised abscess at the tip but no faecal peritonitis. The caecum and terminal ileum appeared viable with no evidence of bowel compromise. Appendicectomy was performed, and the specimen was sent for histopathological examination. The femoral hernia was repaired using the McVay (Cooper's ligament) technique without mesh placement, given the contaminated field.

Histopathology confirmed acute gangrenous appendicitis with serositis and no evidence of malignancy. The patient had an uneventful postoperative recovery. Intravenous antibiotics were continued for 5 days, and she was discharged on day 5 with oral antibiotics to complete a 7-day course. At 6-week follow-up, the wound had healed well with no evidence of recurrence.

Discussion

De Garengeot hernia is an eponymous condition first described by the French surgeon Rene Jacques Croissant de Garengeot in 1731.¹ It refers to the presence of the vermiform appendix within a femoral hernia, regardless of whether the appendix is inflamed. When complicated by acute appendicitis, it represents a diagnostic and surgical challenge.

The condition is exceptionally rare, accounting for only 0.5-1% of all femoral hernias.² Femoral hernias themselves are uncommon, representing approximately 3% of all groin hernias but up to 20% of groin hernias in women.³The anatomical basis for De Garengeot hernia is thought to relate to a mobile caecum or a long appendix that permits the appendix to reach the femoral canal.

Pre-operative diagnosis is achieved in fewer than 50% of cases, with most diagnosed incidentally at surgery.⁴ CT has emerged as the imaging modality of choice when the diagnosis is suspected, with reported sensitivity of 87% when specifically sought.⁵ Key CT findings include a tubular structure within the femoral hernia sac continuous with the caecum, with or without peri-appendiceal inflammatory changes.

Surgical management involves appendicectomy and hernia repair. The approach may be open (inguinal or femoral) or laparoscopic, depending on local expertise and the degree of contamination.⁶ Primary mesh repair is generally avoided in the presence of infection or gangrene due to the risk of mesh infection, although some authors report successful mesh repair in selected cases.⁷

This case is notable for several reasons. To our knowledge, it represents the first reported case of De Garengeot hernia from sub-Saharan Africa. Previous cases have been reported predominantly from Europe, North America, and Australasia, with fewer than 100 cases described in the English literature worldwide.⁸ This geographical disparity likely reflects reporting bias rather than true differences in incidence.

This case also highlights diagnostic challenges in resource-limited settings. While CT was available at this district hospital, many facilities in rural South Africa lack advanced imaging capabilities. A high index of clinical suspicion for complicated femoral hernia is essential, and surgeons should be prepared for unexpected findings at exploration.⁹

In conclusion, De Garengeot hernia is a rare but important differential diagnosis in patients presenting with incarcerated femoral hernia. This first reported case from sub-Saharan Africa underscores the importance of maintaining awareness of rare conditions even in resource-limited settings. Pre-operative CT, when available, can aid in diagnosis and surgical planning.¹⁰