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w w w . c o n t e m p o r a r y s u r g e r y . c o m © 2003 Dow den Health M edia | V O L 5 9 , N O 1 / J A N 2 0 0 3 ■
revealed clear, non-turbid fluid; but
instead of the incarcerated fat that we
expected, we found an incarcerated
appendix (Figure).
D I L EM M A : What should be done about
the appendix? How should this hernia
be repaired?
The herniated appendix could not be
reduced; therefore, the hernia canal
required opening medially and then anteriorly. One
small focal area of the mid-appendix appeared
C LI N I C AL P R E S E N T AT I O N | A 75-year-old
woman with a history of chronic obstructive pul-
monary disease presented with a two-week history
of nagging right inguinal pain and a four-day histo-
ry of a mass in her right groin. She denied fever,
vomiting, or any change in bowel habits. Physical
examination revealed normal vital signs, a soft, non-
tender, non-distended abdomen, and a firm, mildly
tender, non-reducible 3-cm mass in the right groin
about 2 cm below the inguinal ligament. Her leuko-
cyte count was 7.9x103
/mL (reference range,
3.5–10.5x103
/mL). With a preoperative diagnosis of
incarcerated right femoral hernia and no evidence of
incarceration of bowel within the hernia, a 5-cm
transverse, infra-inguinal incision was made. The
hernia sac was identified and opened to ensure that
its contents could be reduced without trauma. This
context Femoral hernias occur infrequently but more often in older, thin
women. Although they can be mistaken as inguinal lymph nodes or incarcerated
inguinal hernias, when anatomic principles of location are considered, they
are usually easy to diagnose and their treatment is, on most occasions,
straightforward. Occasionally, the general surgeon may encounter unexpected
findings in such hernias, and the ideal method of dealing with these “ surprises”
is not always clear. Adherence to surgical principles and knowledge of the local
anatomy is key to a successful outcome. — D. FARLEY, M D ■
■
D E P A R T M E N T E D I T O R ■ DAVID R. FARLEY, M D
Mayo Clinic, Medical School, and
Graduate School of Medicine,
Rochester, Minn
| DILEM M AS |
Incarcerated Appendix in a Femoral Hernia Sac
Diagno stic
&Surgical
DILEMMAS
FERN A N D O CORD ERA , M D ; M I CH A EL G. SA RR, M D
Drs Cordera and Sarr are from the Department of Surgery at the Mayo Clinic, Rochester, Minn.
Correspondence: Fernando Cordera, MD; Mayo Clinic, 200 First Street SW, Rochester, MN 55905; telephone (407) 284-2511;
fax (507) 536-7151 (e-mail: cordera.fernando@mayo.edu).
F I G URE . Hernia sacwith incarcerated appendix.

2. 3 6 ■ V O L 5 9 , N O 1 / J A N 2 0 0 3 c o n t e m p o r a r y s u r g e r y
Diagno stic
&Surgical
DILEMMAS
mildly ischemic, and thus an appendectomy was
performed. The hernia sac was ligated and reduced
above the femoral canal, and the hernia defect was
closed with a polypropylene mesh plug. Two days
later, erythema was noted around her incision. She
was taken back to the operating room, the mesh
was removed, and the defect was closed primarily.
Discharge was uneventful two days later.
D I S C U S S I O N | Femoral hernias occur through a
space bounded superiorly by the iliopubic tract,
inferiorly by Cooper’s ligament, laterally by the
femoral vein, and medially by the insertion of the
iliopubic tract to Cooper’s ligament. Femoral her-
nias account for up to 4% of all groin hernias and
are much more common in women.1
Herniation of
the intestinal tract into femoral hernias occurs in
one third of patients, and the rate of incarceration
is higher (14%–56%) than in inguinal hernias
(6%–10%). Small bowel, colon, Meckel’s diverticu-
lum, and even gastric herniation have been
described. Herniation of the appendix into a
femoral sac, however, is rare. In a series of 655
femoral hernia repairs, Wakeley2
reported the inci-
dence of herniation of the appendix into a femoral
sac as less than 1%. An incarcerated appendix in a
femoral hernia was first reported by De Garengot in
1731.3
By 1974, 242 patients had been reported with
an appendix herniating into a femoral hernia, 59 of
whom presented with acute appendicitis.4
Incarceration is not an indication for appendec-
tomy; however, if the appendix shows signs of
strangulation or inflammation, it should be
removed.5
If the appendix appears viable, not
inflamed, and is easily reduced, resection is unnec-
essary and may be counterproductive because it
can increase the rate of wound infection. In this
particular patient, the appendix appeared to have a
small area of mild ischemia at the incarceration site
and was thus removed.
There are four different anatomic approaches to
a femoral hernia: infra-inguinal; anterior inguinal
(through the posterior inguinal floor); preperi-
toneal; and transperitoneal via an endoscopic, min-
imal access approach. There is no consensus on
which approach is the best, and each has its poten-
tial advantages and disadvantages. The lack of any
preoperative symptoms of gut incarceration led the
senior surgeon (MGS) to approach the hernia in this
older female patient from the least debilitating
approach, i.e. infra-inguinally, fully expecting to
find incarcerated preperitoneal fat. Finding the
appendix instead proved to be a surprise. When
incarceration is suspected preoperatively, a “high”
or more rostral approach provides advantages over
other incisions.6-7
Once the appendectomy has been performed
and the anatomy of the femoral region has been
identified, the surgeon must decide how the defect
should be closed. Although the fluid in the hernia
sac was clear, the appendix was clearly viable, and
the mildly ischemic focus was non-inflamed, the
decision to “plug” the defect to reduce the herniat-
ed content with mesh was in retrospect probably ill-
advised (the senior surgeon agrees!). Prosthetic
material should be avoided whenever possible in
procedures in which contamination is likely. Other
options would have included a primary repair by
sewing the pectineus fascia to the remnants of the
inguinal ligament (this choice was deemed less opti-
mal at the time of surgery because of the enlarge-
ment of the femoral canal needed to mobilize the
appendix) or to make a separate counter-incision
and repair the hernia “from above.” Probably the
former would have been most advisable.
This case, though describing an uncommon
problem, underscores how adherence to surgical
principles should be observed to obtain a successful
outcome. Understanding the clinical problem,
potential complications, and knowledge of the
regional anatomy are key in every patient.
Editor’s comment | What a fantastic specialty! General
surgery allows one to help patients that harbor a
diversity of pathophysiologic abnormalities that oth-
Prosthetic material should be avoided
whenever possible in procedures in
which contamination is likely.

3. References
1. Bay-Nielsen M, Kehlet H, Strand L, et al. Quality assessment of 26,304
herniorrhaphies in Denmark: a prospective nationwide study. Lancet.
2001;358:1124-1128.
2. Wakeley CPG. Hernia of the Vermiform appendix. In: Maingot R, ed,
Abdominal Operations. New York: Appleton Century-Crofts;
1969:1288.
3. Garland EA. Femoral appendicitis. J Indiana Med Assoc. 1955;48:1292-
1294.
4. Voitk AJ, MacFarlane JK, Estrada RL. Ruptured appendicitis in femoral
hernias: report of two cases and review of the literature. Ann Surg.
1974;179:24-26.
5. Naude GP, Ocon S, Bongard F. Femoral hernia: the dire consequences
of a missed diagnosis. Am J Emerg Med. 1997;15:680-682.
6. Wyatt JP, Varma JS. Femoral hernia appendix causing small intestinal
obstruction. Postgrad Med J. 1992;68:223-224.
7. Khatib CM. Strangulated femoral hernia containing acute gangrenous
appendicitis: case report and review of the literature. Can J Surg.
1987;30:50.
ers can only dream of… an appendix incarcerated
in a femoral hernia. The specialty rewards hard-
working young men and women with bountiful
opportunities in clinical and research realms. The
junior author makes good and moves from interna-
tional medical student to general surgery prelim to
categorical trainee at an “ivory tower institution.”
The field generates, cultivates, and perpetuates the
creation of men and women of honor, class, and
humility. The senior author willingly offers up this
dilemma so others may avoid the pitfalls inherent in
contemplating or breaking with surgical dictum.
Bravo! My hat is off to general surgeons everywhere!
—D. FARLEY, MD
Dilemmas: Incarcerated Appendix