Case 1
A 76-year-old woman presented to our hospital with complaints of a right inguinal swelling. Her body temperature was 35.9 ℃, and the mass was not reducible. Blood tests showed a white blood cell (WBC) count of 3400/mm3, hemoglobin 11.9 g/dL, C-reactive protein (CRP) 0.02 mg/dL, albumin 3.7 g/dL, total bilirubin 0.7 mg/dL, blood urea nitrogen 16 mg/dL, and creatinine 0.76 mg/dL, which were not suggestive of an inflammatory reaction. Plain computed tomography (CT) (Fig. 1) revealed a well-defined, isodense, blind-ended tubular structure medial to the right femoral vein. B-mode ultrasonography (US) showed a blind-ended hyperechoic luminal structure protruding from the abdominal cavity (diameter: 4 mm at the body, 6 mm at the tip), a reticular hyperechoic area, and an anechoic area medial to the right femoral vein, which were determined to be the appendix, mesoappendix, and ascites, respectively (Fig. 2a). The appendiceal wall structure (five layers) was clearly visible. Color Doppler US showed pulsatile blood flow signals in the appendiceal wall (Fig. 2b, Additional file 1: video S1). CT and US indicated de Garengeot hernia; however, results of blood studies and US did not suggest appendicitis or appendiceal circulatory compromise. We planned an elective herniorrhaphy, which was performed using a transabdominal preperitoneal approach (TAPP), 28 days later.
The patient was placed in the supine position under general anesthesia, and one 5-mm port each was placed on the umbilicus, umbilical level on the right side of the abdomen, and left lower abdomen. Laparoscopy showed incarceration of the median umbilical fold into the right femoral ring and the free appendix in the abdominal cavity (Fig. 3, Additional file 2: video S2). A fibrous band was also found between the right femoral ring and appendiceal tip, suggesting that the appendiceal tip had previously been in the femoral ring. There was no enlargement or color change in the appendix; therefore, appendectomy was not performed. The median umbilical fold was restored to the abdominal cavity, the peritoneum was incised, and parietalization was performed. Versatex mesh (Covidien) 14 cm × 9 cm was placed in the preperitoneal space and fixed with an Absorber Tack 5 mm (Covidien). The peritoneum was closed using continuous suturing with a 3–0 Polysorb (Covidien).
She was discharged 2 days after the surgery and has shown no sign of hernia recurrence or appendicitis during the 6 months that have passed since the surgery.
Case 2
A 70-year-old woman presented to our hospital with complaints of right inguinal pain and swelling. A 3-cm inguinal mass was palpable; but not manually reducible. Blood test showed slightly elevated WBC count and CRP level (WBC 9500/mm3, CRP 2.23 mg/dL). Contrast-enhanced CT (Fig. 4) showed a blind-ended tubular structure, 6 mm in diameter and continuous with the cecum with contrast enhancement medial to the right femoral vein, suggesting that it was the appendix. B-mode US showed a blind-ended isoechoic structure (5 mm in diameter) which was continuous with the cecum, a surrounding reticular hyperechoic area, and an anechoic area medial to the right femoral vein, which were diagnosed as the appendix, mesoappendix, and ascites, respectively (Fig. 5a). B-mode US showed a clear appendiceal wall structure, and color Doppler US showed pulsatile blood flow signals in the appendiceal wall (Fig. 5b, Additional file 3: video S3). Based on these findings, she was diagnosed with de Garengeot hernia. Antibiotics (levofloxacin 500 mg/day) were administered to prevent potential development of appendicitis, and an elective surgery was performed seven days later.
The patient was placed in the supine position under general anesthesia, and one 5-mm port each was placed on the umbilicus, umbilical level of the right side of the abdomen, and left lower abdomen. Laparoscopy revealed an incarcerated appendiceal tip in the right femoral ring, which was not reducible by traction (Fig. 6a, Additional file 4: video S4). The peritoneum was incised, and parietalization performed. The appendiceal tip was restored to the free abdominal cavity during ablation of the preperitoneal space. Because there was no enlargement, congestion, or color change in the appendix (Additional file 5: video S5), appendicectomy was not performed. Versatex mesh 14 cm × 9 cm (Covidien) was placed in the preperitoneal space and fixed with an Absorber Tack 5 mm (Covidien). The peritoneum was closed with continuous suturing using a 3–0 Polysorb (Covidien).
The postoperative course was uneventful, and she has no signs of hernia recurrence or appendicitis 5 months postoperatively.