Amyand's hernia with acute phlegmonous appendicitis: case report
Abstract and Figures
Any inguinal hernia containing the vermiform appendix is called Amyand's hernia. Amyand hernias are very rare and even rarer is the association of Amyand hernia with acute appendicitis. Due to the rarity of this entity, it constitutes a challenging case in terms of diagnosis and treatment. The surgical management is not yet standardized and there are no clear guidelines. There are some controversies regarding whether to perform an appendectomy if appendix appears normal or whether mesh can be used for the hernia repair if appendectomy is performed. We describe a case of Amyand hernia in a 90-year old man with acute appendicitis and we review current literature regarding surgical strategy.
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... The differential diagnosis includes incarcerated or strangulated inguinal hernia, inguinal lymphadenitis, testicular torsion, acute epididymitis, acute hydrocele, and focal panniculitis. [7] The clinical presentation generally mimics that of an incarcerated inguinal hernia. The diagnosis is generally made at the operating room but in some cases the diagnosis is made preoperatively with the aid of inguinal echography and abdominal tomography. ...
... The diagnosis is generally made at the operating room but in some cases the diagnosis is made preoperatively with the aid of inguinal echography and abdominal tomography. [7] The exact mechanism of appendicitis, within an inguinal hernia is not fully understood. [8] After a thorough review of the existing literature, some opinions are reported below: ...
... In 2007 Losanoff and Basson proposed an Amyand's hernia classification system that can be useful for intraoperative decision making (see table 1). [7] Most of the authors in case of noninflamed appendix do not suggest removal. The transection of a fecal-containing organ in an otherwise clean procedure may increase morbidity and mortality from septic complications and, again, the surgical manipulation, during appendectomy, in the base of the caecum could increase the recurrence rate of the inguinal hernia, due to detachment in the deep inguinal ring. ...
Introduction and importance
Amyand hernia is a rare disease seen in approximatively 1% of all hernias, complications of it, like acute appendicitis, or perforated appendicitis are even more rare, about 0.1%. Its diagnosis is very difficult in the preoperative period: it is usually an incidental finding.
Case presentation
We report an unusual case of perforated gangrenous appendicitis with peri-appendicular abscess occurring in an irreducible Amyand’s hernia. An 80-year-old male, with chronic obstructive disease and pulmonary emphysema, atrial fibrillation, acute myocardial infarction, underwent urgent surgery, under local anesthesia, for right incarcerated inguinoscrotal hernia.
He was found to have a perforated gangrenous appendicitis with peri-appendicular abscess within a right indirect inguinal hernia sac. Appendicectomy and Bassini’s hernia repair were performed under local anesthesia without any complications.
Clinical discussion
The treatment of Amyand’s hernia is not standardized. The current generally accepted algorithm for Amyand’s hernia is essentially contingent on the appendix’s condition within the hernia sac.
Conclusion
Appendectomy and primary herniorrhaphy, under local anesthesia, for type 3 of Amyand’s hernia, is a safe procedure and easy to perform and, if confirmed by further study, could be part of every surgeon’s knowledge.
Inguinal hernia is the most common seen groin hernias which mostly contain bowel. The incidence of vermiform appendix in an inguinal hernia is seen in 1% of all inguinal hernia. This is known as Amyand's hernia. Appendix within a hernia can be normal or complicated by appendicitis. Most of these cases are not diagnosed preoperatively and managed during surgery. Preoperative diagnosis of these cases is so rare. Very few cases have been reported so far.
In our case, we diagnosed an inflamed appendix in a 49 years old female within right inguinal hernia by using ultrasound and confirmed it by CT scan.
October 8, 1735. Hanvil Anderson, a boy, 11 years of age, was admitted into St. George's hospital near Hyde-Park Corner, for the cure of a hernia scrotialis, which he had had from his infancy, and a fistula between the scrotum and thigh terminating into it, which for a month last past had discharged a great quantity of an unkindly sort of matter. The rupture was small, and not troublesome, and part of it could be replaced, but as it appeared that the sinuous ulcer sprung from that part that could not; so 'twas evident that the cure of the fistula depended upon the cure of the hernia, which latter could be obtained by no other operation than that for the Bubonocele, which was agreed to, and performed the 6th day of December following.
Amyand's hernia is a rarity and a recurrent case is extremely rare. A 71-year-old male with a previous history of right inguinal hernia repair presented to the emergency department with a 1-day history of pain in the right groin. A physical examination revealed a nonreducible right inguinal hernia. A computed tomography scan showed a 1.3-cm appendix with surrounding inflammation within a right inguinal hernia. An emergent right groin exploration revealed an incarcerated and injected non-perforated appendix and an indirect hernia. Appendectomy was performed through the groin incision, and the indirect hernia defect was repaired with a biological mesh (Flex-HD). We hereby present this unique case - the first reported case of recurrent Amyand's hernia and a literature review of this anatomical curiosity.
We report two cases of Amyand's hernia, which is the development of acute appendicitis within an inguinal hernia. Both patients were clinically thought to have incarcerated inguinal hernias, but were correctly prospectively diagnosed as having Amyand's hernia on the basis of preoperative computed tomography (CT) examinations. Our cases again show the utility of CT of the acute abdomen and pelvis in revealing a previously unsuspected diagnosis and rapidly triaging patients to the appropriate management.
The diagnosis of acute hernial appendicitis
- T O Burger
- N C Torbert
Burger TO, Torbert NC. The diagnosis of acute hernial appendicitis. Am J Surg. 1938;42:429.