Case Report: A Rare Case of Amyand’s hernia in a 35 year old male patient with a right indirect inguinal hernia

Introduction

Amyand’s hernia (AH) is defined as an inguinal hernia containing the vermiform appendix, whether the vermiform appendix is normal, inflamed, or perforated. Amyand Hernia is a rare disease seen in approximately 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 pre-operative period; it is usually an incidental finding. This poster is a case report of such rare condition.

Case Report

A 35-year old male patient came with complaints of vague right groin swelling with intermittent mild pain and discomfort since 3 months. On examination, he had a positive right groin cough impulse that reduced spontaneously and disappeared with occlusion of the internal ring. He was diagnosed with an indirect right sided inguinal hernia.Laboratory data were within normal limits. Blood pressure was well controlled. The patient was scheduled for elective surgery. The oblique conventional incision between external and internal rings was used to achieve a better approach. Subcutaneous tissue through Scarpa’s fascia was divided until aponeurotic fibres of the external oblique were visualized. After dividing the external oblique to the superficial inguinal ring, the contents of the inguinal canal were then circumscribed using blunt dissection. The hernia sac lateral to the inferior epigastric pedicle was dissected away from the spermatic cord to the deep inguinal ring. The sac was opened illustrating the cecum and vermiform appendix (Fig. 1). There were no inflammatory changes of the appendix or cecum. The sac contents were reduced into the peritoneal cavity. Appendicectomy was done. Hernial sac separated up to the neck of sac. Hernial sac excised. Tension-free polypropylene mesh repair was done. The patient’s postoperative condition was uneventful and he was discharged on the next day. He was followed up at OPD one week and one month later with no complications.

Discussion

Amyand’s hernia is defined as presence of appendix in an inguinal hernia. This rare condition was named after the first surgeon to perform appendectomy, Claudius Amyand, an English surgeon of the 18th century who first described a case of acute appendicitis in a hernial sac in an 11-year-old child1. The incidence of an Amyand’s Hernia is 1% of inguinal hernias occurring most often in male patients. They are most commonly located on the right side due to the location of the appendix. The appendix has also been found in obturator, umbilical and incisional hernias².

Amyand Hernia is most frequently reported in men and almost exclusively on the right side, probably due to the common anatomical position of the appendix³. The disorder comprises less that 1% of all inguinal hernia-casesand 0.2% of appendicitis cases. The incidence of the presence of a uninflammed appendix vermiform is in the sac of an inguinal hernia isestimated to be 0.13%, but it is even rarer to find an inflamed appendix in an inguinal hernia sac. It is most common within the sac, omentum, small intestine or urinary bladder to be found. Aside from these conditions, Meckel’s diverticulum (Littre hernia), part of the intestinal wall (Richter’s hernia) or inflamed or uninflamed vermiformappendix (Amyand’s hernia)⁴.

Amyand’s hernia is difficult to diagnose clinically and is rarely diagnosed preoperatively. A preoperative ultrasonography and computed tomography scanning of the abdomen could be helpful for diagnosis, but this is not a routine practice after the clinical suspicion of a complicated hernia. There have been fewer than 200 cases of Amyand’s hernia in the literature, two of which presenting as scrotal swelling⁵. The decision whether to perform an appendectomy has been addressed by the classification proposed by Losanoff and Basson; in the type 1 Amyand’s hernias (appendix not inflamed), appendicectomy is not routinely undertaken unless the patient is young. In types 2, 3, and 4 Amyand’s hernias (inflamed appendix) appendicectomy is routine^6,7.

Our patient had a Type 1 Amyand’s hernia and underwent a mesh repair with an appendectomy. In the pediatric and young adults population, however, a prophylactic appendectomy would have been performed (without mesh repair), because children and young adults have a higher risk of acquiring acute appendicitis.^6,7