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A groin hernia is known as De Garengeot hernia when the appendix is located within the sac of a femoral hernia, with or without associated acute appendicitis. The true incidence of de Garengeot’s hernia is difficult to assess due to its rarity. Most of the times, De Garengeot hernia are presented acutely when incarcerated which turn them indistinguishable from other incarcerated femoral hernias at clinical examination. Treatment of De Garengeot hernia is an emergency, as it is for any femoral hernia incarcerated. After initial resuscitation, surgical treatment is mandatory without further delay. The surgical approach and the options to consider are dependent on the presence of incarceration and of septic environment at the time of diagnosis.

Background Complicated acute biliary calculous disease poses clinical challenges. The European Society of Trauma and Emergency Surgery (ESTES) snapshot audit of complicated biliary calculous disease aims to make novel comparisons between self‐reported institutional adherence to the Tokyo guidelines (TG18) and ‘real‐world’ contemporary practice across Europe. Methods A preplanned analysis of a prospective observational multicentre audit that captured patients undergoing emergency admission for complicated biliary calculous disease (complicated cholecystitis, biliary pancreatitis, or choledocholithiasis with or without cholangitis) between 1 and 31 October 2018 was performed. An anonymized survey was administered to participating sites. Results Following an open call for participation, 25 centres from nine countries enrolled 338 patients. All centres completed the anonymized survey. Fifteen centres (60 per cent) self‐reported that a minority of patients were treated surgically on index admission, favouring interval cholecystectomy. This was replicated in the snapshot audit, in which 152 of 338 patients (45·0 per cent) underwent index admission cholecystectomy, 17 (5·0 per cent) had interval cholecystectomy, and the remaining 169 (50·0 per cent) had not undergone surgery by the end of the 60‐day follow‐up. Centres that employed a dedicated acute care surgery model of care were more likely to perform index admission cholecystectomy compared with a traditional general surgery ‘on call’ service (57 versus 38 per cent respectively; odds ratio 2·14 (95 per cent c.i. 1·37 to 3·35), P, The Tokyo Guidelines 2018 (TG18) describe expert consensus for best practice in the management of complex acute biliary calculous disease. Self‐reported adherence (and limitations to this) were compared with ‘real‐world’ patient‐level data from a prospective observational study, the ESTES snapshot audit. Recognition of TG18 was high, but adherence to guidance on both index admission cholecystectomy and microbiological culture‐guided antibiotic therapy was poor. Low self‐reported and actual adherence to guidelines