Necrotizing Fasciitis Secondary to Perforated Appendicitis within an Inguinal Hernia Sac: A Case Report and Review of the Literature

Abstract: Background: Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening soft tissue infection requiring immediate surgical debridement and broad-spectrum antibiotic therapy. Its association with perforated appendicitis within an inguinal hernia sac a condition known as a De Garengeot hernia variant is exceedingly rare and carries a high risk of delayed diagnosis owing to its atypical presentation. Case Report: A 50-year-old male with a history of ocular hypertension and gout presented with a painful swelling of the right iliac fossa extending to the right flank. Physical examination revealed a firm, warm, and tender non-fluctuant mass with an associated uncomplicated right inguinal hernia. Laboratory investigations demonstrated a marked inflammatory response (WBC 24,000/mm³, CRP 396 mg/L) with concurrent acute kidney injury, precluding the use of intravenous contrast. Non-contrast CT identified two intraperitoneal collections in the right iliac fossa (9×7 cm and 6×7 cm) extending to the right psoas muscle, along with a 6×13 cm gas-containing parietal collection of the right lateral abdominal wall, consistent with an abscess. Following multidisciplinary review, the patient underwent emergency laparotomy with peritoneal drainage and cutaneous necrosectomy. Intraoperative findings revealed a perforated, inflamed appendix incarcerated within the right inguinal hernia sac. Appendicectomy was performed laparoscopically. Daily wound care was carried out in theatre, and the patient was discharged after 10 days with a favorable outcome. Conclusion: Perforated appendicitis within an inguinal hernia sac complicated by necrotizing fasciitis is a rare surgical emergency. The diagnosis relies on a high index of clinical suspicion and early CT imaging. A combined surgical approach laparoscopic appendicectomy, open drainage, and aggressive soft tissue debridement is essential to optimize outcomes.