Thread by @RyanChristieMD

Wetread Case 37

Hx: abd/pelvic pain. Palpable mass

Please answer with professionally appropriate gif responses only. No spoilers! wetread.org #WetreadCow #FOAMrad #FOAMed #radres #errad #bodyrad @RyanBPetersonMD @ER_Rad_Hanna @StefanTigges @AdamSingerMD

Wetread Case 37 Answer: De Garengeot Hernia with acute appendicitis

A De Garengeot hernia is a femoral hernia containing the appendix. Here we have that but the appendix is hyperenhancing with wall thickening and surrounding fluid consistent with acute appendicitis. #FOAMrad

De Garengeot hernias were named after a French surgeon from the 1700s. These are fairly rare (<3% of femoral hernias), with complicating appendicitis even more uncommon.

Understanding groin hernias can take time and practice and even then they can be difficult.

There are 2 major types we will focus upon: inguinal hernias and femoral hernias

Inguinal hernias are the most common abdominal wall hernia (~80%). In these, intraabdominal contents herniates into the inguinal canal. These are much more common in males (5x-7x vs female). There are two types

1) Indirect Inguinal Hernia
-More common
-due to a)congenital defect process vaginalis (young pt) or b) acquired do to weakness of the inguinal ring (older pt)
-extend through deep inguinal ring
-LATERAL to the inferior epigastric artery
-anterior or around the spermatic cord

2) Direct
- less common
- secondary to weakness in floor of inguinal canal (Hesselbach’s triangle)
- MEDIAL to inferior epigastric artery (therefore inguinal contents generally displaced laterally)

Image below shows the inferior epigastric vessels (orange) so the fat lateral to the vessels would be the INDIRECT hernia (blue) and the fat medial the the vessels would be the DIRECT hernia (red). But both go into the inguinal canal, just through different routes.

A femoral hernia herniates through the femoral ring, so inferior to inguinal ligament and lateral to the inguinal canal. It can compress the normal femoral canal contents, primarily the femoral vein (green arrow) as we see in our pt here.

You tend to see femoral hernias lying on top of the pectineus muscle as it lies on the superior pubic ramus.

Here we see a small fat containing femoral hernia (yellow) compared to a normal inguinal canal (blue)

Groin hernia summary:

Inguinal hernia extend inf and medial into inguinal canal. Direct take a "direct course" medial to inf epigastric a. vs Indirect go more "indirectly" lateral to vessels

Femoral hernias go inf and lateral through femoral ring compressing the femoral vein.

"Fancy" Groin hernias:

Amyand hernia = inguinal hernia containing appendix (some say specifically appendicitis 😮)

De Garengeot hernia = femoral hernia containing appendix (or appendicitis as we see here!) 😃

Labels: Hernia yellow, appendix red #FOAMed #FOAMRad #bodyrad #errad