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Amyand's hernia masquerading as a strangulated inguinal hernia: A case report and literature review.

Byline: Shahbaz. Faridi, Afzal. Anees, Bushra. Siddiqui, Nadeem. Ahmed

We report a rare case of a 62-year-old male who presented to surgical emergency department with the complaints of sudden onset pain and swelled in the right inguinal region with nausea, vomiting and abdominal distension. There was a history of a reducible swelling in the right inguino-scrotal region for the last 1 year. Based on history, clinical examination and investigations a provisional diagnosis of right-sided strangulated inguinal hernia was made and patient was planned for an emergency surgery. On the exploration, the hernial sac revealed a gangrenous vermiform appendix and the diagnosis of Amyand's hernia was made. Appendectomy was performed through the same incision, and hernial repair was done using a polypropylene mesh.

Introduction

The incidence of obstructed and strangulated inguinal hernia is 0.3-2.9% of all inguinal hernias in adults. [sup][1] There are have been many case reports in the literature regarding the contents of strangulated inguinal hernia such as ovary, fallopian tube, gangrenous bladder diverticula, large bowel diverticula, and Meckel's diverticulum (Littre's hernia).

Amyand's Hernia is a very rare type of inguinal hernia in which inflamed appendix is present inside the hernial sac. The eponym "Amyand hernia" was first suggested by Creese in 1953, then by Hiatt and Hiatt in 1988, followed by Hutchinson in 1993, in honor of Claudius Amyand (1680-1740) who performed appendectomy in an 11-year-old boy having perforated appendix as a content of inguinal hernia in 1735. This was also the first successful operation for acute appendicitis. [sup][2]

Preoperative diagnosis of such type of hernia is very difficult, and most of the cases that have been reported in the literature were diagnosed intraoperatively. [sup][3]

Case Report

A 62-year-old male presented to the emergency department with the complaints of sudden onset pain and swelling in the right groin along with vomiting and abdominal distension for last 1 day. On further inquiry, patient gave a history of a reducible swelling at the similar site since last 1 year, which he ignored as it was not causing any problem. Vitals of the patient were normal. Routine investigations were also normal except for a slightly raised differential leucocyte count (11,500/cu mm). On physical examination, a slightly tender and irreducible right inguinal hernia was found. Abdominal ultrasonography and radiographs of the abdomen were taken in erect and supine positions that were normal.

Provisional diagnosis of right-sided strangulated inguinal hernia was made, and emergency surgery was planned. Operation was done by inguinal incision under spinal anesthesia. On the exploration an indirect inguinal hernia sac [Figure 1] was present which was dissected and opened [Figure 2]a. The content was found to be inflamed appendix [Figure 2]b with adherent omentum. Adhesions of omentum to the appendix were removed by blunt dissection and appendectomy was done [Figure 3]. The remaining stump along with caecum was delivered back into the abdominal cavity, and inguinal area was irrigated with 3 L of normal saline. The hernia repair was done using Prolene mesh and polypropylene sutures [Figure 4]. Broad-spectrum intravenous antibiotics were given for 3 days. Postoperative stay of the patient was uneventful, and he was discharged after 3 days. The follow-up was uneventful, and there was no recurrence of hernia.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

Discussion

The life-time probability of a person to have acute appendicitis is 8%, and occurrence of an asymptomatic appendix within a hernia sac is rare, which accounts for 1%. [sup][4] However, the incidence of acute appendicitis in a sac of inguinal hernia is even less common. Ryan in 1937 reported that 11 out of 8692 cases (0.13%) of acute appendicitis were located in external hernia sac. [sup][5] Thomas et al . found 7 cases of acute appendicitis occurring in an external hernia sac during 8 years. [sup][6] The average age of occurrence of inguinal hernia containing inflamed appendix was calculated as 69.4 years and range was from 3 weeks to 88 years. The age of our patient was 62 years.

Amyand's hernia is almost always present on the right side, but there have been some case reports of left-sided Amyand's hernia also. Diagnosis of Amyand's hernia is almost always made intraoperatively because the usual clinical picture is identical to that of an incarcerated hernia although ultrasound and computed tomography can help. [sup][7] However, in one case study the diagnosis was made preoperatively. [sup][8] Differential diagnosis of Amyand's hernia includes Strangulated hernia, Richter's hernia, testicular torsion, testicular tumor with hemorrhage, inguinal adenitis, epidydimitis and orchitis. Appendectomy with primary hernia repair using the same incision is used for the treatment of Amyand's hernia. In the presence of uncomplicated vermiform appendix in the sac of inguinal hernia, the mesh hernia repair without appendectomy is recommended by most authors. [sup][9] However, in case of perforated appendix in the sac, appendectomy with delayed mesh hernia repair is suggested by some authors. [sup][10],[11] Nonetheless, some authors prefer to perform both appendectomies and mesh hernia repair in the treatment of the inflamed appendix in the inguinal hernia sac. They recommend intravenous broad-spectrum antibiotics for at least 3-5 days to prevent mesh infection. [sup][7],[12] Torino et al . recommended irrigation of the inguinal area with antibiotics. [sup][12] In our case, the appendix was congested and inflamed with an adhesive caecum inside the sac, but no abscess was observed. We irrigated the inguinal canal with 3 L of normal saline instead of antibiotics and performed appendectomy with mesh hernia repair.

Conclusion

Presence of acute appendicitis in inguinal hernia sac is a very rare finding, but misdiagnosis is not rare when it occurs. Diagnosis of the condition is almost always made intraoperatively. In our opinion mesh should be applied in the selected group of patients with Amyand's hernia in whom pus has not formed, after thorough irrigation of the inguinal canal with normal saline.

Conflict of Interest

None of the authors has any conflict of interest to disclose.

Patient Consent

Written consent was obtained from the patient for the publication.

References

1. Gongora-Gomez EM. Strangulated inguinal hernia. Et Cir Cir 2012;80:357-67.

2. Amyand C. Of an inguinal rupture, within a pin in the appendix caeci, incrusted with Stone, and some observations on wounds in the guts. Philos Trans R Soc Lond 1736;39:329-36.

3. Mohamed AA, Bhatty TA, Mahmoud AR, Abukhater M. Amyand: A forgotten surgeon and hernia. Case presentation and literature review. Internet J Urol 2009;7:1.

4. Sengul I, Sengul D, Aribas D. An elective detection of an Amyand's hernia with an adhesive caecum to the sac: Report of a rare case. N Am J Med Sci 2011;3:391-3.

5. Ryan WJ. Hernia of the vermiform appendix. Ann Surg 1937;106:135-9.

6. Thomas WE, Vowles KD, Williamson RC. Appendicitis in external herniae. Ann R Coll Surg Engl 1982;64:121-2.

7. Michalinos A, Moris D, Vernadakis S. Amyand's hernia: A review. Am J Surg 2014;207:989-95.

8. Weber RV, Hunt ZC, Kraal JG. Amyand's hernia: Etiologic and therapeutic implications of the two complications. Surg Rounds 1999;22:552-6.

9. Psarras K, Lalountas M, Baltatzis M, Pavlidis E, Tsitlakidis A, Symeonidis N, et al. Amyand's hernia - A vermiform appendix presenting in an inguinal hernia: A case series. J Med Case Rep 2011;5:463.

10. Logan MT, Nottingham JM. Amyand's hernia: A case report of an incarcerated and perforated appendix within an inguinal hernia and review of the literature. Am Surg 2001;67:628-9.

11. Ranganathan G, Kouchupapy R, Dias S. An approach to the management of Amyand's hernia and presentation of an interesting case report. Hernia 2011;15:79-82.

12. Torino G, Campisi C, Testa A, Baldassarre E, Valenti G. Prosthetic repair of a perforated Amyand's hernia: Hazardous or feasible? Hernia 2007;11:551-2.
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Article Details
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Title Annotation:Case Report
Author:Faridi, Shahbaz; Anees, Afzal; Siddiqui, Bushra; Ahmed, Nadeem
Publication:Journal of Medical Sciences
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2014
Words:1303
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