Amyand's Hernia: inguinal hernia with acute appendicitis

INTRODUCTION

The presence of a vermiform appendix inside a hernial sac is not a common condition⁷. In the literature, the reported incidence is around 1% of all hernias⁶. It is even rarer to find an acute appendicitis inside the inguinal hernia⁴.

When the cecal appendix, inflamed or not, is found in the inguinal sac, it is called an Amyand hernia⁵. This kind of hernia is more frequent in men and pre-operative diagnosis is not easy⁹. It must be suspected in patients with a tense inguinal hernia with no signs of intestinal obstruction. The appendectomy will always be carried out at the same time as the repair of the hernia.

The aim of the present study is to present a case of acute appendicitis within a right inguinoscrotal hernia and to review the literature.

CASE REPORT

A 35-year-old male farmworker arrived at the General Surgery Service of the Hospital Universitário Oswaldo Cruz, Recife, Pernambuco, Brazil. He reported the appearance of a mass in the right inguinoscrotal region for around one month without pain. Two days previously he had begun to experience epigastric pain with nausea and vomiting. He visited his local health service and received treatment for gastritis. As the pain continued and was located in the right iliac fossa, he was admitted to hospital. A physical examination revealed a heart rate of 100 bpm, a respiratory rate of 21 ipm, PA=130x80 mmHg and an inguinoscrotal hernia on the right side with slight irritation of the peritoneum. He was referred for surgery and the procedure revealed an inflamed appendix with purulent secretion at its apex within the hernial sac. As surgical access was by transverse incision of the inguinal hernia, it was decided to perform the appendectomy and the Bassini repair of the hernia simultaneously (Figure 1). Antibiotic prophylaxis with metronidazole and ceftriaxone was carried out for 24 hours. After two days, the patient was discharged from hospital with no complications. The result of a biopsy confirmed the appendicitis.

Figure 1 -
Inflamed cecal appendix in a right inguinoscrotal hernia

DISCUSSION

Some authors believe that a cecal appendix in an inguinal hernia was first described by De Garengeot in 1731¹⁰. Claudius Amyand (1681-1740), a French surgeon, who was a refugee in England, was the first to perform an appendectomy^{13 , 11}. The appendix is found in the hernial sac in around 1% of inguinal hernias and an inflamed appendix is found in only 0.13% of cases.

A variant of this, an appendix inside a femoral hernia, is called a Garengeot hernia⁴. In 1937, Ryan described 11 cases of acute appendicitis (within an inguinal hernia) among 8,692 cases of appendicitis¹². Another author¹ reported 10 cases of appendicitis within an inguinal hernia over nine consecutive years.

The etiopathogenesis of acute appendicitis is unclear. Many authors believe there is an association between incarceration and inflammation of the cecal appendix in the hernial sac, that is, an ischemic phenomenon deriving from compression of the organ by the hernial ring leading to appendicitis¹⁴. Typical symptoms of acute appendicitis, such as initial epigastric pain settling later in the right iliac fossa, nausea, vomiting and anorexia may also be seen in patients with an Amyand hernia. According to the literature, fever and leukocytosis are not common in these patients¹³. Pre-operative diagnosis is unusual. In an article reviewing 50 cases of Amyand's hernia, only one case was diagnosed prior to surgery¹⁴.

The presence of peritoneal irritation and early pain in an incarcerated hernia may suggest appendicitis inside the hernial sac. The use of imaging methods may assist diagnosis⁴.

Surgery is mandatory. However, the kind of surgery recommended subject to controversy. In most circumstances, treatment involves an emergency appendectomy and repair of the hernia⁸. When there is a risk of complications, such as a pericecal abscess, the appendectomy should be pre-peritoneal to minimize possible infection of the wound and recurrence of the hernia².

REFERENCES

• ¹
  Carey LC. Acute appendicitis occurring in hernias: a report of 10 cases. Surgery 1967; 61:236-8.
• ²
  Doyle GS, McCowan C. Amyand hernia: a case of an unusual inguinal herniace. Am J Emerg Med 2008; 26(5):637. e5-6.
• ³
  Franko J, Sulkowki R. A rare variation of Amyand's Hernia. Am J Gastroenterol 2002; 97(10):2684-5.
• ⁴
  Gillion JF, Bornet G, Hamrouni A, Jullès MC, Convard JP. Amyand and de Garengeot' hernias. Hernia 2007; 11(3):289-90
• ⁵
  Hiatt JR, Hiatt N. Amyand's hernia. N Engl J Med 1988; 318(21):1402.
• ⁶
  Hotiana MM, Kundu S, Ahmad I. Complicated inguinal hernia of Amyand. South Med J 2007; 100(4):411.
• ⁷
  Lippolis PV, Barlettai M, Filidei F, Seccia M. The Amyand's hernia. Case report and review of the literature. Ann Ital Cir 2007; 78(2):153-7.
• ⁸
  Logan MTBS, 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(7)628-9.
• ⁹
  Losanoff JE, Basson MD. Amyand hernia: what lies beneath--a proposed classification scheme to determine management. Am Surg 2007; 73(12):1288-90.
• ¹⁰
  Priego P, Lobo E, Moreno I, Sánchez-Picot S, Gil Olarte MA, Alonso N, Fresneda V. Acute appendicitis in an incarcerated crural hernia: analysis of our experience. Rev Esp Enferm Dig (Madrid) 2005; 97(10):707-715.
• ¹¹
  Rodríguez Montes JA. Historias de la cirugía. AstraZeneca 2003; 87-102.
• ¹²
  Ryan WJ. Hernia of the vermiform appendix. Ann Surg 1937; 106:135-9.
• ¹³
  13. Torres Hernández D, Roselló Fina JR, del Campo Abad R, Canals Rabasa PP, Enríquez Weinmann ES. Hernia de Amyand: presentación de un caso y revisión de la literatura. Arch Cir Gen Dig 2003; 22 Sep. Available at: www.cirugest.com.
  » www.cirugest.com
• ¹⁴
  Weber RV, Hunt ZC, Kral JC. Amyand's hernia. Etiologic and therapeutic implications of two complications. Surg Rounds 1999; 22:552-6.

• Financial source: none

Publication Dates

• Publication in this collection
  Nov-Dec 2014

History

• Received
  06 June 2013
• Accepted
  19 Aug 2014