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Painful Right Inguinal Swelling

Painful Right Inguinal Swelling Case A 69-year-old man presented to the emergency department with a 5-day history of painful right inguinal swelling. His medical history included hypertension, peptic duodenal ulcer, and resection of a melanoma of the right foot associated with inguinal lymphadenectomy performed 3 years earlier. He also reported a similar episode of ipsilateral inguinal swelling punctured and diagnosed as seroma 5 months earlier. Physical examination revealed a right inguinal irreducible swelling that was painful on palpation. The rest of the abdomen was soft and normal except for pain in the right iliac fossa. There was no local inflammatory aspect. Laboratory testing showed normal white blood cell count, slight increase of C-reactive protein level (10 mg/L [to convert to nanomoles per liter, multiply by 9.524]; normal range, 0-5 mg/L) and mild renal impairment (creatinine level, 1.4 mg/dL [to convert to micromoles per liter, multiply by 76.25]; normal range, 40-105 mg/dL). A contrast-enhanced abdominopelvic computed tomography revealed a hypodense mass located at the right groin region, with a targetlike image within it (Figure 1). Figure 1. Abdominopelvic computed tomography images show axial (A) and multiplanar reformatted (B) views. A indicates anterior; AR, anterior right; FL, foot left; HR, head right; L, left; P, posterior; PL, posterior left; and R, right. View LargeDownload Box Section Ref ID What Is Your Diagnosis? Melanoma metastatic lymphadenopathy Incarcerated femoral hernia containing the appendix Incarcerated groin hernia–containing bowel loop Groin abscess Read the Discussion. Discussion Diagnosis B. Incarcerated femoral hernia containing the appendix Discussion Femoral hernias account for 4% of all groin hernias and usually contain the small bowel, the colon, or the omentum.1 They are frequently strangulated and therefore managed surgically in emergency. A femoral hernia containing the appendix is rare, accounting for less than 5% of femoral hernias, and is known as De Garengeot hernia because it was first described in 1731 by French surgeon René Jacques Croissant De Garengeot.2 It must be distinguished from Amyand hernia, which is an inguinal hernia containing the appendix, and from Littre hernia, which contains Meckel diverticulum.3,4 Typically, De Garengeot hernia is asymptomatic and diagnosed intraoperatively during surgical repair of an uncomplicated groin hernia.5 However, in some cases, it may be revealed by a clinical presentation of strangulated femoral hernia, associating vague pain, and an erythematous groin lump, but with no evidence of bowel obstruction or appendicitis. Indeed, the symptoms are usually strictly limited to the groin anatomical region because they are secondary to appendicular strangulation and not to appendicitis.6 Additionally, the tight femoral hernia neck and pelvic rigidity prevent the spread of inflammation to the peritoneal cavity. Radiological examinations are seldom performed in the setting of femoral hernia, as the diagnosis is mainly clinical. However, the presence of a low-positioned cecum, along with tubular structure within the hernial sac and stranding of nearby fat on computed tomography, is highly suggestive for appendicitis within a hernial sac.7 The management of this entity requires emergency surgery consisting of simultaneous appendectomy and primary hernia repair. The traditional open approach, which may be feasible only if appropriate exposure of the appendix origin on the cecum is provided, has been recently challenged by combined inguinal and laparoscopic or full laparoscopic approach.2,5,8,9 In the present case, a computed tomographic scan was performed in view of the patient’s medical history of malignancy and inguinal seroma, and the diagnosis was therefore made preoperatively. A low curved inguinal incision was performed and allowed appropriate exposure for both femoral canal repair and appendectomy (Figure 2). Surgical exploration revealed no abscess in the hernial sac and no evidence of perforation. The appendix was ligated and divided at its base, while the femoral canal was closed according to the McVay technique.10 The postoperative course was uneventful and the patient was discharged home on postoperative day 2. Histologic examination of the specimen showed an inflammatory appendix with no signs of malignancy. Figure 2. A low curved inguinal incision allowed appropriate exposure for both femoral canal repair and appendectomy. View LargeDownload Back to top Article Information Corresponding Author: Kayvan Mohkam, MD, Department of General Surgery and Liver Transplantation, Hospices Civils de Lyon, Hôpital de la Croix-Rousse, 103, Grande Rue de la Croix-Rousse, 69317 Cedex 04, Lyon, France (kayvan.mohkam@chu-lyon.fr). Published Online: January 6, 2016. doi:10.1001/jamasurg.2015.2766. Conflict of Interest Disclosures: None reported. Additional Contributions: We thank the patient for granting permission to publish this information. Section Editor: Pamela A. Lipsett, MD, MHPE. References 1. Fitzgibbons RJ Jr, Forse RA. Clinical practice: groin hernias in adults. N Engl J Med. 2015;372(8):756-763.PubMedGoogle ScholarCrossref 2. Kalles V, Mekras A, Mekras D, et al. De Garengeot’s hernia: a comprehensive review. Hernia. 2013;17(2):177-182.PubMedGoogle ScholarCrossref 3. Michalinos A, Moris D, Vernadakis S. Amyand’s hernia: a review. Am J Surg. 2014;207(6):989-995.PubMedGoogle ScholarCrossref 4. Zuniga D, Zupanec R. Littre hernia. JAMA. 1977;237(15):1599.PubMedGoogle ScholarCrossref 5. Sharma H, Jha PK, Shekhawat NS, Memon B, Memon MA. De Garengeot hernia: an analysis of our experience. Hernia. 2007;11(3):235-238.PubMedGoogle ScholarCrossref 6. Kagan Coskun A, Kilbas Z, Yigit T, Simsek A, Harlak A. De Garengeot’s hernia: the importance of early diagnosis and its complications. Hernia. 2012;16(6):731-733.PubMedGoogle ScholarCrossref 7. Fukukura Y, Chang SD. Acute appendicitis within a femoral hernia: multidetector CT findings. Abdom Imaging. 2005;30(5):620-622.PubMedGoogle ScholarCrossref 8. Comman A, Gaetzschmann P, Hanner T, Behrend M. DeGarengeot hernia: transabdominal preperitoneal hernia repair and appendectomy. JSLS. 2007;11(4):496-501.PubMedGoogle Scholar 9. Beysens M, Haeck L, Vindevoghel K. Laparoscopic appendectomy combined with TEP for de Garengeot hernia: case report. Acta Chir Belg. 2013;113(6):468-470.PubMedGoogle Scholar 10. Halverson K, McVay CB. Inguinal and femoral hernioplasty. Arch Surg. 1970;101(2):127-135.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Painful Right Inguinal Swelling

Fanget, Florian; Cotte, Eddy; Mohkam, Kayvan
JAMA Surgery , Volume 151 (3) – Mar 1, 2016
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References (11)

Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2015.2766
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Abstract

Case A 69-year-old man presented to the emergency department with a 5-day history of painful right inguinal swelling. His medical history included hypertension, peptic duodenal ulcer, and resection of a melanoma of the right foot associated with inguinal lymphadenectomy performed 3 years earlier. He also reported a similar episode of ipsilateral inguinal swelling punctured and diagnosed as seroma 5 months earlier. Physical examination revealed a right inguinal irreducible swelling that was painful on palpation. The rest of the abdomen was soft and normal except for pain in the right iliac fossa. There was no local inflammatory aspect. Laboratory testing showed normal white blood cell count, slight increase of C-reactive protein level (10 mg/L [to convert to nanomoles per liter, multiply by 9.524]; normal range, 0-5 mg/L) and mild renal impairment (creatinine level, 1.4 mg/dL [to convert to micromoles per liter, multiply by 76.25]; normal range, 40-105 mg/dL). A contrast-enhanced abdominopelvic computed tomography revealed a hypodense mass located at the right groin region, with a targetlike image within it (Figure 1). Figure 1. Abdominopelvic computed tomography images show axial (A) and multiplanar reformatted (B) views. A indicates anterior; AR, anterior right; FL, foot left; HR, head right; L, left; P, posterior; PL, posterior left; and R, right. View LargeDownload Box Section Ref ID What Is Your Diagnosis? Melanoma metastatic lymphadenopathy Incarcerated femoral hernia containing the appendix Incarcerated groin hernia–containing bowel loop Groin abscess Read the Discussion. Discussion Diagnosis B. Incarcerated femoral hernia containing the appendix Discussion Femoral hernias account for 4% of all groin hernias and usually contain the small bowel, the colon, or the omentum.1 They are frequently strangulated and therefore managed surgically in emergency. A femoral hernia containing the appendix is rare, accounting for less than 5% of femoral hernias, and is known as De Garengeot hernia because it was first described in 1731 by French surgeon René Jacques Croissant De Garengeot.2 It must be distinguished from Amyand hernia, which is an inguinal hernia containing the appendix, and from Littre hernia, which contains Meckel diverticulum.3,4 Typically, De Garengeot hernia is asymptomatic and diagnosed intraoperatively during surgical repair of an uncomplicated groin hernia.5 However, in some cases, it may be revealed by a clinical presentation of strangulated femoral hernia, associating vague pain, and an erythematous groin lump, but with no evidence of bowel obstruction or appendicitis. Indeed, the symptoms are usually strictly limited to the groin anatomical region because they are secondary to appendicular strangulation and not to appendicitis.6 Additionally, the tight femoral hernia neck and pelvic rigidity prevent the spread of inflammation to the peritoneal cavity. Radiological examinations are seldom performed in the setting of femoral hernia, as the diagnosis is mainly clinical. However, the presence of a low-positioned cecum, along with tubular structure within the hernial sac and stranding of nearby fat on computed tomography, is highly suggestive for appendicitis within a hernial sac.7 The management of this entity requires emergency surgery consisting of simultaneous appendectomy and primary hernia repair. The traditional open approach, which may be feasible only if appropriate exposure of the appendix origin on the cecum is provided, has been recently challenged by combined inguinal and laparoscopic or full laparoscopic approach.2,5,8,9 In the present case, a computed tomographic scan was performed in view of the patient’s medical history of malignancy and inguinal seroma, and the diagnosis was therefore made preoperatively. A low curved inguinal incision was performed and allowed appropriate exposure for both femoral canal repair and appendectomy (Figure 2). Surgical exploration revealed no abscess in the hernial sac and no evidence of perforation. The appendix was ligated and divided at its base, while the femoral canal was closed according to the McVay technique.10 The postoperative course was uneventful and the patient was discharged home on postoperative day 2. Histologic examination of the specimen showed an inflammatory appendix with no signs of malignancy. Figure 2. A low curved inguinal incision allowed appropriate exposure for both femoral canal repair and appendectomy. View LargeDownload Back to top Article Information Corresponding Author: Kayvan Mohkam, MD, Department of General Surgery and Liver Transplantation, Hospices Civils de Lyon, Hôpital de la Croix-Rousse, 103, Grande Rue de la Croix-Rousse, 69317 Cedex 04, Lyon, France (kayvan.mohkam@chu-lyon.fr). Published Online: January 6, 2016. doi:10.1001/jamasurg.2015.2766. Conflict of Interest Disclosures: None reported. Additional Contributions: We thank the patient for granting permission to publish this information. Section Editor: Pamela A. Lipsett, MD, MHPE. References 1. Fitzgibbons RJ Jr, Forse RA. Clinical practice: groin hernias in adults. N Engl J Med. 2015;372(8):756-763.PubMedGoogle ScholarCrossref 2. Kalles V, Mekras A, Mekras D, et al. De Garengeot’s hernia: a comprehensive review. Hernia. 2013;17(2):177-182.PubMedGoogle ScholarCrossref 3. Michalinos A, Moris D, Vernadakis S. Amyand’s hernia: a review. Am J Surg. 2014;207(6):989-995.PubMedGoogle ScholarCrossref 4. Zuniga D, Zupanec R. Littre hernia. JAMA. 1977;237(15):1599.PubMedGoogle ScholarCrossref 5. Sharma H, Jha PK, Shekhawat NS, Memon B, Memon MA. De Garengeot hernia: an analysis of our experience. Hernia. 2007;11(3):235-238.PubMedGoogle ScholarCrossref 6. Kagan Coskun A, Kilbas Z, Yigit T, Simsek A, Harlak A. De Garengeot’s hernia: the importance of early diagnosis and its complications. Hernia. 2012;16(6):731-733.PubMedGoogle ScholarCrossref 7. Fukukura Y, Chang SD. Acute appendicitis within a femoral hernia: multidetector CT findings. Abdom Imaging. 2005;30(5):620-622.PubMedGoogle ScholarCrossref 8. Comman A, Gaetzschmann P, Hanner T, Behrend M. DeGarengeot hernia: transabdominal preperitoneal hernia repair and appendectomy. JSLS. 2007;11(4):496-501.PubMedGoogle Scholar 9. Beysens M, Haeck L, Vindevoghel K. Laparoscopic appendectomy combined with TEP for de Garengeot hernia: case report. Acta Chir Belg. 2013;113(6):468-470.PubMedGoogle Scholar 10. Halverson K, McVay CB. Inguinal and femoral hernioplasty. Arch Surg. 1970;101(2):127-135.PubMedGoogle ScholarCrossref

Journal

JAMA Surgery – American Medical Association

Published: Mar 1, 2016

Keywords: differential diagnosis,hernia, femoral,hernia, inguinal,pain,diagnostic imaging,femoral herniorrhaphy,leukocyte count

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