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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 3  |  Page : 176-179

Case series on different presentations of Amyand's hernia


1 Department of Surgery, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Department of Surgery, Nalanda Medical College and Hospital, Patna, Bihar, India

Date of Web Publication17-Mar-2017

Correspondence Address:
Nameer Faiz
Department of Surgery, Indira Gandhi Institute of Medical Sciences, Patna - 800 014, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.202373

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  Abstract 

A vermiform appendix in an inguinal hernia is known as Amyand's hernia. The incidence of having a normal appendix within the hernia sac varies from 0.5% to 1%, whereas only 0.1% of cases complicate into acute appendicitis, underscoring the rarity of the condition. This is a case series of three cases with different presentations and their management. The first case is of a 42-year-old male who was admitted as a routine case of a right-sided indirect inguinal hernia, with a history of occasional pain in the swelling. On surgical exploration of the sac, contents of the hernia sac included omentum and an acutely inflamed appendix with the appendix densely adherent to the hernia sac. Appendicectomy was performed and a herniotomy was done. A herniorrhaphy was performed by modified Bassini repair. The second case is of a 28-year-old young male who presented with a right-sided indirect inguinal hernia. He had no specific complaints associated with the hernia. He was operated under local anesthesia and intraoperatively in the hernia sac, appendix was an incidental finding and an appendicectomy was not performed. The third case is of a 58-year-old man who presented to the emergency with an obstructed hernia. The patient was operated upon in the emergency operation room, and on opening the sac, there was serosanguineous collection and the cecum along with the inflamed appendix. Appendicectomy was done without stump inversion. The superficial inguinal ring was found to be constricting the neck of hernia sac, which was divided. Routine herniotomy and herniorrhaphy was done by modified Bassini method.

Keywords: Acute appendicitis, amyand's Hernia, appendix in hernia sac, Bassini's repair, inguinal hernia, obstructed hernia


How to cite this article:
Faiz N, Ahmad N, Singh R. Case series on different presentations of Amyand's hernia. Arch Int Surg 2016;6:176-9

How to cite this URL:
Faiz N, Ahmad N, Singh R. Case series on different presentations of Amyand's hernia. Arch Int Surg [serial online] 2016 [cited 2018 Nov 18];6:176-9. Available from: http://www.archintsurg.org/text.asp?2016/6/3/176/202373




  Introduction Top


Inguinal hernia may display very unusual sac contents. Ovary,  Fallopian tube More Details, urinary bladder, incarcerated bladder diverticula, large bowel diverticula in the form of diverticulitis or abscess, Meckel's diverticulum (littre hernia) have been rarely reported.[1],[2] The presence of the appendix within an inguinal hernia has been referred to as “Amyand's hernia” to honor Claudius Amyand, surgeon to King George II. Amyand was the first to describe the presence of a perforated appendix within the inguinal hernia sac of an 11-year-old boy, and performed a successful transherniotomy appendicectomy in 1735.[3] Three cases of Amyand hernia operated at our centre in a cohort of 285 inguinal hernia patients are presented here.


  Case Reports Top


Case 1

A 42-year-old male was admitted as a routine case of right-sided reducible indirect inguinal hernia since 2 years. Patient complained of occasional episodes of pain in the hernia, which resolved on antibiotic therapy. Full blood count revealed leucocytosis of 10400/mm 3 and neutrophilia of 84%. Ultrasonography report was inconclusive. A diagnosis of strangulated inguinal hernia was made. The patient was put on parenteral antibiotics before the surgery. A standard right inguinal incision was made; the hernia sac was unexpectedly bluish in color. The sac was densely adherent to the cord structures; when the sac was opened, it contained serosanginous fluid which was drained. The contents of the sac included omentum and an acutely inflamed appendix with a fecolith in the mid part [Figure 1]. An appendicectomy was performed, and herniorrhaphy was done by modified Bassini's method. Mesh hernioplasty was avoided for the risk of mesh infection. The patient had a smooth postoperative recovery and was discharged on the 6th postoperative day without any complications. Patient was followed up for 2 years and reported no complaints.
Figure 1: Acutely inflamed appendix in the hernia sac

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Case 2

A 28-year-old young man who presented with a right-sided inguinal hernia since 1 year. The patient complained of dragging pain during straining. On examination, the hernia was of indirect, incomplete, and reducible type. During operation under local anesthesia, the sac was found to contain an appendix. The appendix was normal with no visible neovascularization and there were no adhesions to the sac. The appendix was reduced back to the abdomen, herniotomy was performed, and Lichtenstein mesh hernioplasty was done. The patient was discharged after an uneventful recovery. Two year follow up showed no symptoms of appendicitis.

Case 3

A 58-year-old male patient presented to our surgical emergency with a tender, erythematous right inguinal mass. He had a right-sided inguinal hernia since 4 years. His medical history included type II diabetes mellitus and chronic hypertension. Pain onset was sudden and involved the right inguinal area. Body temperature was raised. Laboratory findings included leukocytosis (13000/mm 3) and elevated C-reactive protein (53 mg/L). A diagnosis of incarcerated hernia to exclude an abscess was made. On exploration, obstructed inguinal hernia was found. After opening the sac and suction of serosangineous foul smelling collection, inflamed appendix was found inside the hernia sac, along with part of the cecum and omentum [Figure 2]. All adhesions were released and appendectomy [Figure 3] with resection of inflamed parts of omentum was done, along with excision of the sac. Modified Bassini procedure was performed. The postoperative period was uneventful. The patient had intravenous antibiotics for 4 days. The patient was followed up for 1.5 years, during which he had no inguinal or abdominal complaints, after which he was lost to follow-up.
Figure 2: Cecum and inflamed appendix in hernia sac of obstructed hernia

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Figure 3: Appendicectomy being performed after ligation of mesoappendix in hernia sac

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  Discussion Top


A hernia is defined as the protrusion of a viscus or part of a viscus through the walls of its containing cavity. The first description of an appendix in inguinal hernia is attributed to Amyand, a sergeant surgeon to King George I and II who, in 1735, found a perforated appendix in an 11-year-old boy who presented with a right inguinal hernia and fecal fistula.[3] This was also one of the first documented descriptions of an appendectomy being performed.[4] The incidence of having a normal appendix within the hernia sac varies from 0.5% to 1%, even left-sided Amyand's hernia have been reported,[5] whereas only 0.1% of all cases of acute appendicitis present in an inguinal hernia, underscoring the rarity of the condition.[6] Previous reports have also emphasized on the rarity of this condition.[6],[7] However, because we found three cases in a short duration of 3 years, the incidence rate in our case series is approximately 1.05% (3/285). Increased incidence found in these areas can be attributed to the general neglect of patients in getting the hernia operated; the time gap is generally approximately 3–5 years between the diagnosis and surgery. Inflammation of the appendix is attributed to external compression of the appendix at the neck of the hernia. The inflammatory status of the vermiform appendix determines the surgical approach and the type of hernia repair. As in the first and third cases in this series, it is widely accepted that, if appendicitis exists, the repair of the hernia should be performed with modified Bassini or Shouldice techniques, without making use of synthetic meshes or plugs within the defect[7] in an infected field owing to the high risk of suppuration of such materials.[8] Management should be individualized according to appendix's inflammation stage, presence of abdominal sepsis and co-morbidity. The Losanoff-Basson classification [7] as shown in [Table 1] offers a satisfactory guidance system.
Table 1: Losanoff-Basson classification

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Most surgeons agree that the presence of acute appendicitis (Losanoff–Basson type 2–4) within a hernia should be a contraindication for the use of synthetic meshes or plugs. However, a point of disagreement is whether or not to perform an appendectomy in a case of a Losanoff–Basson type 1 Amyand's hernia with normal appendix within inguinal hernia. The decision should be based on factors such as the patient's age, the size and anatomy of the appendix, the side in which the hernia occurs, and extension of the intraoperative manipulations that can by themselves trigger an inflammatory process. We performed an appendicectomy in the first and third case (both Type 2), especially because the appendix was inflamed in both the cases. It was not performed in the second case because of the presence of a normal appendix (Type 1), and also because surgery was being performed under local anesthesia and anesthesia conversion was not considered necessary for the patient. A 2-year follow-up showed that the decision was prudent. The authors want to highlight the absence of a preoperative diagnosis [9] in such cases due to the lack of usage of computed tomography scan [10] and MRI in our country, and mostly the diagnosis is intraoperative as the patient undergoes surgical exploration for a complicated or a simple inguinal hernia.


  Conclusions Top


Amyand's hernia, although a rare condition worldwide, had an incidence of 1.05% in our case series. The diagnosis in all the three cases was made intraoperative, hence, we conclude that a preoperative diagnosis is rarely made in such cases. Management should be individualized according to appendix's inflammation stage, presence of abdominal sepsis, and comorbidity factors. The decision should be based on factors such as the patient's age, the size and anatomy of the appendix, and in case of appendicitis, standard appendectomy and herniorrhaphy without a mesh should be the standard of care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gurer A, Ozdogan M, Ozlem N, Yildirim A, Kulacoglu H, Aydin R. Uncommon content in groin hernia sac. Hernia 2006;10:152-5.  Back to cited text no. 1
    
2.
Greenberg J, Arnell TD. Diverticular abscess presenting as an incarcerated inguinal hernia. Am Surg 2005;71:208-9.  Back to cited text no. 2
    
3.
Amyand C. Of an inguinal rupture, with a pin in the appendix caeci incrusted with stone, and some observations on wound in the guts. Philos Trans Royal Soc 1736;39:329-42.  Back to cited text no. 3
    
4.
Komorowski AL, Moran Rodriguez J. Amyand's hernia. Historical perspective and current considerations. Acta Chir Belg 2009;109:563-4.  Back to cited text no. 4
    
5.
Ravishankaran P, Mohan G, Srinivasan A, Ravindran G, Ramalingam A. Left sided Amyand's hernia, A Rare Occurrence: A Case Report. Indian J Surg 2013;75:247-8.  Back to cited text no. 5
    
6.
Malayeri AA, Siegelman SS. Amyand's Hernia. N Engl J Med 2011;364:2147.  Back to cited text no. 6
    
7.
Losanoff JE, Basson MD: Amyand hernia: A classification to improve management. Hernia 2008;12:325-6.  Back to cited text no. 7
    
8.
Milanchi S, Allins AD. Amyand's hernia: History, imaging, and management. Hernia 2008;12:321-2.  Back to cited text no. 8
    
9.
Anagnostopoulou S, Dimitroulis D, Troupis TG, Allamani M, Paraschos A, Mazarakis A, et al. Amyand's hernia: A case report. World J Gastroenterol 2006;12:4761-63.  Back to cited text no. 9
    
10.
Luchs JS, Halpern D, Katz DS. Amyand's hernia: Prospective CT diagnosis. J Comput Assist Tomogr 2000;24:884-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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