Complicated inguinal hernia of Amyand.

To the Editor: The presence of acute appendicitis in the sac of inguinal hernia is an extremely rare condition, and very few cases have been reported in the literature. The condition, called Amyand hernia, was named for Claudius Amyand, who first described this disorder in an 11-year-old boy in 1735.

A 41-year-old African-American male with HIV disease presented with a swollen and tender right groin for one week. He denied nausea, vomiting, dysuria or urethral discharge. Examination revealed an irreducible right inguinal hernia with severe localized tenderness and warmth. A CT scan of the abdomen was consistent with the appendix herniating into the inguinal sac. During surgery, an inflamed appendix was seen adhering to the wall of the inguinal sac. The appendix was removed and a Bassini repair was performed.

The presence of the appendix in the hernial sac is found in only 1% of inguinal hernias, (1) and an inflamed appendix is found in the inguinal hernia in only 0.13% of cases. (2) Males are more commonly affected than females. Diagnosis is difficult to make preoperatively. Amyand hernia may be suspected in a tender hernia without the signs and radiological findings of an obstruction. (3) CT scan can sometimes be helpful in guiding the diagnosis. The differential diagnosis of Amyand hernia includes strangulated hernia, strangulated omentocoele, Richter hernia, testicular tumor with hemorrhage, acute hydrocoele, inguinal adenitis and epididymitis. (4) Abu Dalu and Urca (5) have proposed that it results from entrapment of the appendix in the hernial sac leading to adhesion formation and compromise of its blood supply, which then causes inflammation and bacterial overgrowth.

The treatment of hernial appendicitis is appendectomy through the herniotomy with primary hernia repair using the same incision. (1,4) Mesh should not be used in the treatment of contaminated abdominal wall defects because the prosthetic material can increase the risk of wound infection and appendiceal stump fistula. (3)

Amyand hernia is an extremely rare condition and is often misdiagnosed. CT of the abdomen may help in guiding the diagnosis as in our case. Its association with HIV infection is not documented in the literature and most likely represents a coincidence in our patient.

Mateen M. Hotiana, MD

Sarba Kundu, MD

Imran Ahmad, MD

Mercy Catholic Medical Center

Darby, PA

Department of Medicine

Wake Forest University

Winston-Salem, NC

References

1. Lyass S, Kim A, Bauer J. Perforated appendicitis in an inguinal hernia: case report and review of literature. Am J Gastroenterol 1997;92:700-702.

2. House MG, Goldin SB, Chen H. Perforated Amyand's hernia. South Med J 2001;94:496-498.

3. Logan MT, Nottingham JM. Amyand's hernia: a case report of an incarcerated and perforated appendix with an inguinal hernia and review of literature. Am Surg 2001;67:628-629.

4. Solecki R, Matyja A, Milanowski W. Amyand's hernia: a report of two cases. Hernia 2003;7:50-51.

5. Abu-Dalu J, Urca I. Incarcerated inguinal hernia with a perforated appendix and periappendicular abscess: report of a case. Dis Colon Rectum 1972;15:464-465.

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