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Paper text:
a 77-year - old lady presented to the emergency room with a right groin mass that had appeared suddenly 4 days before and then gradually increased in size .
her past medical history was significant for hypertension , gastroesophageal reflux disease ( gerd ) , and right inguinal hernia repair 30 years before .
she denied fevers , nausea , vomiting , change in bowel habits , or any urinary symptoms and did not have any recent trauma . on admission ,
abdominal examination revealed a soft , obese , and nondistended abdomen with a large , tender mass in the right inguinal region , measuring 18 cm  10 cm .
the mass was firm to palpation and nonreducible , with erythema of the overlying skin .
no peritoneal signs were elicited , and the remainder of the patient 's physical examination was unremarkable .
laboratory data showed a significant white blood cell count of 19,100/mm but were otherwise within normal range . a recurrent ,
incarcerated inguinal hernia was suspected , but the lack of systemic or abdominal symptoms and the absence of findings suggesting bowel obstruction was concerning .
the differential diagnosis of a localized abscess of uncertain origin was also considered . a computed tomographic ( ct ) scan of the abdomen and pelvis
was obtained to help differentiate between intraabdominal and localized pathology and to plan our surgical approach . a 3 cm  6 cm lobulated fluid collection in the anterior abdominal wall in the right inguinal region was seen . stranding and thickening of the adjacent anterior abdominal wall fat
the primary concern was for an incarcerated , recurrent inguinal hernia resulting in tissue necrosis and abscess formation .
ct scan of the abdomen showing the abscess - like collection ( white arrow ) in the right lower quadrant .
an infraumbilical incision was made , and pneumoperitoneum was obtained by using hasson 's open technique .
a blunt port was then inserted through the incision and a 10-mm , 30-degree scope was used to examine the abdominal cavity .
a major portion of the appendix was seen to pass through a defect adjacent to the inguinal ligament .
two 5-mm abdominal ports were placed , one in the left lower quadrant and the other in the right upper quadrant .
an incision was made externally over the right groin swelling and then carried down to the hernia sac , which appeared to be a femoral hernia .
dissection was carried down to the neck of the sac , which was then ligated , followed by excision of the sac .
the inferior portion of the inguinal ligament and the pectineus fascia were then approximated by using 0 polypropylene sutures .
the rest of the wound was closed in layers , by using absorbable sutures for deep subcutaneous layer and staples for skin .
the patient had an uneventful postoperative period and was discharged to her home on the second day after surgery .
she was seen twice afterwards as an outpatient , once for removal of the drain and a second time for removal of staples .
an infraumbilical incision was made , and pneumoperitoneum was obtained by using hasson 's open technique .
a blunt port was then inserted through the incision and a 10-mm , 30-degree scope was used to examine the abdominal cavity .
a major portion of the appendix was seen to pass through a defect adjacent to the inguinal ligament .
two 5-mm abdominal ports were placed , one in the left lower quadrant and the other in the right upper quadrant .
an incision was made externally over the right groin swelling and then carried down to the hernia sac , which appeared to be a femoral hernia .
dissection was carried down to the neck of the sac , which was then ligated , followed by excision of the sac .
the inferior portion of the inguinal ligament and the pectineus fascia were then approximated by using 0 polypropylene sutures .
the rest of the wound was closed in layers , by using absorbable sutures for deep subcutaneous layer and staples for skin .
the patient had an uneventful postoperative period and was discharged to her home on the second day after surgery .
she was seen twice afterwards as an outpatient , once for removal of the drain and a second time for removal of staples .
the appendix being present within a femoral hernia is an unusual incidental finding at surgery , occurring in 0.8% to 1% of all femoral hernias .
this interesting condition was first described in 1731 by the french surgeon rene jacques croissant de garengeot .
even more rare is the presence of acute appendicitis within a femoral hernia , and hevin in 1785 first described an appendectomy in one such case .
complications such as rupture and abscess formation have been described in a handful of cases .
a review of the literature indicates the incidence of de garengeot hernias to be greater in women , paralleling the sex - related incidence of femoral hernias .
the diagnosis is a difficult one to make preoperatively , and only 2 reports of a positive ct diagnosis are available in literature .
the patient is usually an elderly female with a few days ' history of a painful groin swelling , suggestive of an incarcerated hernia or a groin abscess .
these patients seldom develop signs of peritonitis , as the inflamed appendix is isolated from the peritoneal cavity by the tight neck of the hernia sac .
frequently , the inflamed or ruptured appendix is a surprise finding when the groin swelling is explored .
no standard approach to treatment of de garengeot hernias has been described , possibly due to the rarity of this condition .
various authors have suggested different surgical options ranging from initial open drainage and interval appendectomy and hernia repair , to initial appendectomy followed by interval hernia repair . in previously reported cases
when the groin was explored first , it was often not possible to reach the base of the appendix , and a formal laparotomy became necessary .
in our patient , the unusual presentation of the hernia prompted us to do a diagnostic laparoscopy first , during which the appendix was seen entering the hernia sac .
we were therefore able to promptly perform an appendectomy laparoscopically , eliminating the need for laparotomy and peritoneal contamination .
we were also able to anticipate the contents of the hernia before opening the sac .
the same approach can be applied to acute appendicitis occurring within an inguinal hernia ( also known as amyand hernia ) .
we therefore recommend initial diagnostic laparoscopy in the treatment of groin hernias with atypical presentations and when the contents of the hernia can not be determined either clinically or radiologically . to the best of our knowledge ,
de garengeot hernia is a rare condition in which appendicitis occurs within a femoral hernia .
initial diagnostic laparoscopy can be an invaluable adjunct in both diagnosis and treatment of atypical hernias .
background and objectives : we report a case of appendicitis presenting in an incarcerated femoral hernia , otherwise known as de garengeot hernia . 
 this rare hernia usually presents with both diagnostic and therapeutic dilemmas . 
 we wish to underline the usefulness of laparoscopy in both the diagnosis and treatment of de garengeot hernias.methods:a diagnostic laparoscopy was performed initially . 
 the appendix was seen to disappear into the hernia sac . 
 a laparoscopic appendectomy was then performed prior to open exploration of the groin.results:we were able to obtain a correct diagnosis and perform an appendectomy prior to making a groin incision . 
 operative findings included an incarcerated , inflamed appendix within a femoral hernia.conclusions:diagnostic laparoscopy could be a valuable tool in the correct diagnosis and management of unusual presentations of incarcerated groin hernias .