Presentation
24 hour history of right lower quadrant pain and a very firm tender lump in the right inguinal region with overlying evidence of cellulitis. Afebrile, mildly tachycardic. Abdomen was soft with no diffuse peritonitis or masses. Elevated WCC 16.0.
Patient Data
CASE OF THE MONTH: This case was selected as the Case of the Month for April 2023.
FINDINGS: Large right femoral hernia, containing the appendix. The appendix tip is abnormally dilated at 11 mm diameter, and displays a hypoenhancing wall with moderate volume of adjacent fluid, suspicious for ischemia and perforation. The hernia sac also contains a moderate volume of fat. The sac wall is thickened and there is marked inflammatory stranding of the adjacent subcutaneous fat. As expected, the common femoral vein is severely effaced by the hernia, but remains patent. The common femoral artery is normal.
No other acute bowel abnormality. No other abdominal wall hernia. Normal urinary bladder. No pelvic cyst or mass. Hysterectomy. No acute bony abnormality. Left total hip arthroplasty.
IMPRESSION: Acute appendicitis with suspicion for perforation at the tip, contained within a right femoral hernia (De Garengeot hernia). There is also inflammatory change of the sac wall, which could represent strangulation, or could be secondary to appendicitis.
Surgery:
Acute appendicitis incarcerated in femoral hernia found in the OR. 10cc pus in hernia sac. Patient underwent laparoscopic appendectomy with counter incision in the right inguinal region for drainage of abscess and repair of femoral hernia.
Pathology:
A. Vermiform Appendix, Appendectomy: - Acute appendicitis with acute periappendicitis
B. Hernia Sac, Excision: - Features compatible with hernia sac and areas of acute inflammation, compatible with incarcerated appendix with acute appendicitis.
Case Discussion
Patient did well and was discharged home 3 days post surgery.
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