1289 Rare Case of a Patient with Simultaneous Incarcerated Epigastric Hernia and De Garengeot Hernia: A Case Report

Case Presentation 66-year-old lady presents to surgical unit with main complaint of epigastric pain and swelling. She noticed lump in both groins. She had no previous abdominal surgery and has no past medical history. Examination and bloods Patient had irreducible tender swelling in epigastrium. Additionally, there was irreducible hot tender swelling in right groin. Left groin had soft reducible swelling. C-Reactive protein was 57 and white cell count was 7.9. Imaging CT Abdomen and Pelvis showed incarcerated epigastric hernia with omental fat and right inguinal hernia containing inflamed appendix. Operative findings Epigastric hernia had a 2cm defect containing pre-peritoneal fat. Right groin hernia constituted inflamed appendiceal tip within the femoral canal. Management Initial management included IV fluids and IV antibiotics. The first half of the operation involved mesh repair of epigastric hernia. The second half of the operation involved an incision for inguinal hernia repair and standard appendicectomy through dissection of lacunar ligament and desarda’s repair to the inguinal canal. Patient was discharged on the first post-operative day. Conclusions De Garengeot’s hernia is femoral hernia containing appendix with incidence of 0.15-5% of all femoral hernias. Systematic reviews demonstrate lack of clarity on whether inflamed appendix herniates or herniated appendix develops inflammation. In this case, appendicitis was confined to the tip raising possibility of the latter. Perhaps, strangulation at femoral canal prevented appendicitis to track up the rest of the appendix, which may explain the predominance of patient’s epigastric symptoms. Careful examination is necessary in patients with multiple hernias to guide appropriate operative management.