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Appendicitis incarcerated in a femoral hernia
APPENDICITIS
INCARCERATED
IN A FEMORAL
HERNIA
CASE REPORT CHARLES STANLEY KNAPP, M.D. AND LUDOVIC VINCENT CLAPS, M.D. Senior Surgeon on Attending Staff, Greenwich Hospital Assistant Surgeon on Attending Staff, Greenwich HospitaI GREENWICH,
CONNECTICUT
T
HE Indicus Medicus has been reviewed for a period of ten years, from 1932 to 1943, both under femoraI hernias and under appendix, and no reference to a case of the type herein reported couId be found. We, therefore, submit this case as a first reported operation of an appendix incarcerated in a femoraI hernia.
and there was no tenderness. The extremities showed no edema or cyanosis. Admission diagnosis was right femora1 hernia, incarcerated. Urinalysis was negative. The white bIood count was 9,400 with 79 per cent polymorphonucIears. The case was considered operabIe, and with a preoperative diagnosis the same as the admission diagnosis, repair of the femora1 hernia was attempted under avertin, gasoxygen-ether anesthesia. There was a femora1 hernia about 4 cm. by 4 cm., oval in shape, tense, with the properitonea fat over it hemorrhagic and friabIe. It was fiIIed with straw-coIored fIuid and the vermiform appendix which was swoIIen, edematous, marked in a punctate fashion with dark hemorrhagic areas. The meso-appendix at the tip of the appendix was swoIIen to about 2 cm. in diameter and media1 to this was thinned out. Even after remova of the swoIIen portion of the meso-appendix, the appendix couId not be reduced. After opening the upper abdomen, a11 but about I cm. of the appendix was seen to be in the sac. The appendicea1 artery entered the appendix through the mesentery about 45 cm. from the base. After reducing the appendix by traction above, and pushing from below through the Iower wound, the hernia1 orifice wouId not admit the IittIe finger. The cecum was attached we11 down by peritoneal reflections to the IateraI and posterior abdominal wall. A three-inch incision was made beIow and paraIIe1 to Poupart’s Iigament over the mass. The skin was waIIed off by toweIs, dissection was carried down to the sac, the sac was opened, the appendix was seen to be in the sac and was apparentIy acute; an unsuccessfu1 attempt was made to reduce it. The mesoappendix within the sac was ligated and excised from the appendix, and stiI1 the appendix couId not be reduced, nor couId the cecum be puIIed through the neck of the sac. A Iow McBurney
CASE REPORT The patient, L. J. No. 39375, had a Iump in the right groin for one year. About one year ago, with no known preceding etioIogy or trauma, the patient noticed a smaII Iump in his right groin, which was neither painful nor tender. There had been no associated symptoms unti1 ten days prior to admission, when the mass became suddenly larger and tender. There was a sharp pain on ffexion of the body. The pain did not radiate and became constant twenty-four hours prior to admission. The boweIs were reguIar and normaI, and there never had been signs of obstruction or stranguIation. There were no urinary complaints. Review of symptoms was entireIy negative except for IocaI condition. Two years previousIy the patient had an episode of acute cystitis which responded we11 to treatment. PhysicaI examination reveaIed the patient to be a we11 developed, we11 nourished, sixtytwo year oId white maIe, who did not appear iI1. In the right groin, lateral to the pubic spine, there was an elongated, egg-sized, tense, and moderateIy tender mass, which was smooth and fixed and not reducible. The externa1 inguinal ring was diIated but no impulse couId be feIt on coughing or straining. With the examining finger inside the externa1 inguinal ring, the mass seemed to be entireIy IateraI to the cana waI1. The left inguinaI ring was aIso diIated, but no hernia was found. BIood pressure was r44/go. The abdomen was soft and not distended. No organs were paIpabIe, I39
I40
American Journal
of Surgery
Knapp,
CIaps-Appendix
incision was then made, and the appendix was deIivered by traction from above with a moderate amount of pressure from below. The sac neck was so tight that the muscuIaris of the appendix was divided about an inch from the base in its entire circumference, but the mucosa was not torn. The appendix was removed by Iigation and division of the remaining meso-appendix to the base, clamp and cautery, with inversion of the stump through a linen purse-string. A figure-of-eight catgut on an atraumatic needle was pIaced over the inversion. The peritoneum was then cIosed by a continuous plain catgut suture. The transversal& internal obIique, and externa1 obIique were closed by interrupted No. I plain catgut sutures. The superficia1 fascia was cIosed by fine interrupted pIain catgut, and interrupted silk was used for the skin. The hernia1 sac was then dissected down to its base, ligated, and removed. The stump of the sac was retracted we11 inside of the ring. One No. z chromic suture was used to close the opening of the ring which wouId not admit the tip of the little finger. The hemorrhagic properitoneal fat which had been dissected from the sac was removed, and the deep areas of the wound
and Hernia
APRIL, ,944
were cIosed by interrupted sutures of No. o plain catgut. Another layer of interrupted sutures was pIaced in the superficial fascia, and interrupted silk was used for the skin. The specimen showed a femoral hernia sac, appendix, meso-appendix and fat. The appendix was 8 cm. Iong and I cm. wide; its serosa was rough, congested and denuded in the midline. The appendix was much thickened by old connective tissue. The epithelium was activeIy secreting mucus. There was some Iymphocytic exudate and some eosinophilic infiItration but no pus. The peritonea1 coat contained greatIy engorged bIood vessels but showed a very minor inff ammatory reaction. Various parts of the accompanying pieces of tissue were congested fat, or fat with some productive connective tissue as in adhesions, aIso congested but only miIdIy inflamed. Diagnosis: Chronic appendicitis with recent peri-appendiceal congestion; congested omental or meso-appendix adhesions. His postoperative course was uneventfu1; the sutures were removed on the eighth day and the patient was discharged as cured on the sixteenth day.
INCARCERATED
IN A FEMORAL
HERNIA
CASE REPORT CHARLES STANLEY KNAPP, M.D. AND LUDOVIC VINCENT CLAPS, M.D. Senior Surgeon on Attending Staff, Greenwich Hospital Assistant Surgeon on Attending Staff, Greenwich HospitaI GREENWICH,
CONNECTICUT
T
HE Indicus Medicus has been reviewed for a period of ten years, from 1932 to 1943, both under femoraI hernias and under appendix, and no reference to a case of the type herein reported couId be found. We, therefore, submit this case as a first reported operation of an appendix incarcerated in a femoraI hernia.
and there was no tenderness. The extremities showed no edema or cyanosis. Admission diagnosis was right femora1 hernia, incarcerated. Urinalysis was negative. The white bIood count was 9,400 with 79 per cent polymorphonucIears. The case was considered operabIe, and with a preoperative diagnosis the same as the admission diagnosis, repair of the femora1 hernia was attempted under avertin, gasoxygen-ether anesthesia. There was a femora1 hernia about 4 cm. by 4 cm., oval in shape, tense, with the properitonea fat over it hemorrhagic and friabIe. It was fiIIed with straw-coIored fIuid and the vermiform appendix which was swoIIen, edematous, marked in a punctate fashion with dark hemorrhagic areas. The meso-appendix at the tip of the appendix was swoIIen to about 2 cm. in diameter and media1 to this was thinned out. Even after remova of the swoIIen portion of the meso-appendix, the appendix couId not be reduced. After opening the upper abdomen, a11 but about I cm. of the appendix was seen to be in the sac. The appendicea1 artery entered the appendix through the mesentery about 45 cm. from the base. After reducing the appendix by traction above, and pushing from below through the Iower wound, the hernia1 orifice wouId not admit the IittIe finger. The cecum was attached we11 down by peritoneal reflections to the IateraI and posterior abdominal wall. A three-inch incision was made beIow and paraIIe1 to Poupart’s Iigament over the mass. The skin was waIIed off by toweIs, dissection was carried down to the sac, the sac was opened, the appendix was seen to be in the sac and was apparentIy acute; an unsuccessfu1 attempt was made to reduce it. The mesoappendix within the sac was ligated and excised from the appendix, and stiI1 the appendix couId not be reduced, nor couId the cecum be puIIed through the neck of the sac. A Iow McBurney
CASE REPORT The patient, L. J. No. 39375, had a Iump in the right groin for one year. About one year ago, with no known preceding etioIogy or trauma, the patient noticed a smaII Iump in his right groin, which was neither painful nor tender. There had been no associated symptoms unti1 ten days prior to admission, when the mass became suddenly larger and tender. There was a sharp pain on ffexion of the body. The pain did not radiate and became constant twenty-four hours prior to admission. The boweIs were reguIar and normaI, and there never had been signs of obstruction or stranguIation. There were no urinary complaints. Review of symptoms was entireIy negative except for IocaI condition. Two years previousIy the patient had an episode of acute cystitis which responded we11 to treatment. PhysicaI examination reveaIed the patient to be a we11 developed, we11 nourished, sixtytwo year oId white maIe, who did not appear iI1. In the right groin, lateral to the pubic spine, there was an elongated, egg-sized, tense, and moderateIy tender mass, which was smooth and fixed and not reducible. The externa1 inguinal ring was diIated but no impulse couId be feIt on coughing or straining. With the examining finger inside the externa1 inguinal ring, the mass seemed to be entireIy IateraI to the cana waI1. The left inguinaI ring was aIso diIated, but no hernia was found. BIood pressure was r44/go. The abdomen was soft and not distended. No organs were paIpabIe, I39
I40
American Journal
of Surgery
Knapp,
CIaps-Appendix
incision was then made, and the appendix was deIivered by traction from above with a moderate amount of pressure from below. The sac neck was so tight that the muscuIaris of the appendix was divided about an inch from the base in its entire circumference, but the mucosa was not torn. The appendix was removed by Iigation and division of the remaining meso-appendix to the base, clamp and cautery, with inversion of the stump through a linen purse-string. A figure-of-eight catgut on an atraumatic needle was pIaced over the inversion. The peritoneum was then cIosed by a continuous plain catgut suture. The transversal& internal obIique, and externa1 obIique were closed by interrupted No. I plain catgut sutures. The superficia1 fascia was cIosed by fine interrupted pIain catgut, and interrupted silk was used for the skin. The hernia1 sac was then dissected down to its base, ligated, and removed. The stump of the sac was retracted we11 inside of the ring. One No. z chromic suture was used to close the opening of the ring which wouId not admit the tip of the little finger. The hemorrhagic properitoneal fat which had been dissected from the sac was removed, and the deep areas of the wound
and Hernia
APRIL, ,944
were cIosed by interrupted sutures of No. o plain catgut. Another layer of interrupted sutures was pIaced in the superficial fascia, and interrupted silk was used for the skin. The specimen showed a femoral hernia sac, appendix, meso-appendix and fat. The appendix was 8 cm. Iong and I cm. wide; its serosa was rough, congested and denuded in the midline. The appendix was much thickened by old connective tissue. The epithelium was activeIy secreting mucus. There was some Iymphocytic exudate and some eosinophilic infiItration but no pus. The peritonea1 coat contained greatIy engorged bIood vessels but showed a very minor inff ammatory reaction. Various parts of the accompanying pieces of tissue were congested fat, or fat with some productive connective tissue as in adhesions, aIso congested but only miIdIy inflamed. Diagnosis: Chronic appendicitis with recent peri-appendiceal congestion; congested omental or meso-appendix adhesions. His postoperative course was uneventfu1; the sutures were removed on the eighth day and the patient was discharged as cured on the sixteenth day.