Table of Contents

2016 Month : December Volume : 2 Issue : 2 Page : 11-13.

AMYAND S HERNIA - A RARE SLIDING HERNIA.

Aditya Adhav1

1General Surgeon, Department of General Surgery, Adhav Hospital, Shivajinagar, Nasik.

Corresponding Author:
Dr. Aditya Adhav,
Adhav Hospital,
Shivajinagar,
Nasik-422006.
E-mail: adityaadhav25@gmail.com

ABSTRACT

BACKGROUND

The presence of vermiform appendix in inguinal hernia, referred to as Amyand’s hernia, is a rare occurring in about 1% of inguinal hernias. This is a report of Amyand’s hernia, which presented as a sliding component in a right inguinal hernia in a male patient. Appendicectomy and herniotomy were performed, with an uneventful postoperative recovery.

KEYWORDS

Amyand’s Hernia, Appendiceal Sliding Hernia, Inguinal Hernia.

BACKGROUND

The contents of inguinal hernia sacs differ from case to case. Various structures contained therein have been described, but the presence of the appendix in an inguinal hernia sac is rare.

This anomaly was first described by Claudius Amyand in an 11-year-old boy who underwent a successful appendicectomy in 1735.1,2 The incidence of appendicitis within an inguinal hernia is estimated at 0.07–0.13%.1,3,4,5 The eponym Amyand’s hernia was first coined by Creese in 1953, then by Hiatt in 1988, followed by Hutchinson in 1993.6,7,8,9 We report a case of Amyand's hernia.

CASE REPORT

A 19-year-old male was admitted for right inguinal hernia repair. He had the hernia for six months. It was increasing in size, especially during walking, but was reducible upon lying down. Examination showed swelling in the right inguinal region, which was nontender, reducible, and had a positive cough impulse.

The patient underwent all investigations for per anaesthesia fitness and was posted for surgery after getting fitness. Per-operatively, he was found to have a hernia sac containing an appendix (Figure 1 & 2). An appendicectomy and herniotomy repair were performed. The patient had an unremarkable recovery and was discharged ten days after the surgery. He was seen for follow-up after one month; the incision site was uninfected.

Figure-1

 

Figure-2

 

DISCUSSION

A hernia is the protrusion of the viscus or a part of the viscus through the wall of its containing cavity. By far the most commonly encountered hernia is in the inguinal region which also normally contains bowels or omentum. Among the unusual contents are the bladder, Meckel’s diverticulum (Known as Littre’s hernia), or a portion of the circumference of the intestine (Called Richter’s hernia). French surgeon Rene-Jacques Croissant de Garengeot described the presence of an appendix within the femoral hernia sac, the so-called de Garengeot hernia.10 But Amyand’s hernia is relatively unknown despite being first reported in 1735 by Claudius Amyand.1 The term Amyand’s hernia is used to refer to a hernial sac containing an inflamed or non-inflamed appendix in an irreducible inguinal hernia.11 Losanoff and Basson suggested a distinct classification to improve the management of Amyand’s hernias.12,13 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 (See Table 1).

 

Classification

Description

Surgical

Management

Type 1

Normal appendix in

inguinal hernia

Hernia reduction,

mesh repair; appendicectomy

in young patients.

Type 2

Acute appendicitis within an inguinal hernia and no abdominal sepsis

Appendicectomy through hernia;

primary repair

of hernia; no mesh

Type 3

Acute appendicitis within an inguinal hernia or the

abdominal wall, or

peritoneal sepsis

Laparotomy; appendicectomy;

primary repair of

hernia; no mesh

Type 4

Acute appendicitis within an inguinal hernia with

related or unrelated

abdominal pathology

Manage as hernias

type 1–3; investigate

or treat second

pathology

as appropriate

 

The incidence of a normal appendix being found inside an inguinal hernia sac is about 1%; however, only 0.1% of these cases have appendicitis.Solecki et al observed that acute appendicitis was found in 0.62% of all groin hernia sacs.14,15 In most of the patients who present with a right-sided Amyand’s hernia, its location can be explained by the normal anatomical position of the appendix; also, right sided inguinal hernias are more common, however, left-sided Amyand’s hernias have also been described in the literature and may be associated with situs inversus, malrotation of the gut, long appendix or mobile caecum11.The pathophysiology of Amyand’s hernia is unknown. Weber et al proposed that due to herniation the appendix can become more vulnerable to micro-trauma, causing adherence to the hernia sac due to fibrosis.16 This hypothesis that inflammatory swelling may lead to incarceration, subsequent impaired blood supply, and bacterial overgrowth was supported by Abu Dalu, Barut, and House.17,18,19 Muscle contractions and changes in abdominal pressure can cause compression of the appendix, resulting in reduced blood supply and secondary inflammation.15 Diagnosing Amyand’s hernia pre-operatively is not straight forward. In the majority of cases, it is diagnosed when the hernia sac is opened, as most patients undergo emergency surgery. Although a preoperative computed tomography (CT) scan of the abdomen can be helpful in diagnosing the condition, it is not routinely employed in such cases. If the diagnosis is established by CT, it is possible to treat Amyand’s hernia laparoscopically.20 The recommended treatment is appendicectomy with primary hernia repair. Use of synthetic mesh is avoided in the repair of contaminated abdominal defects because prosthetic material can increase the inflammatory response and result in wound infection and a rare but possible complication of appendiceal stump fistula.21 Preigo et al carried out appendectomies in six patients, using mesh in three. One patient developed a wound infection after being treated with mesh.22 Bailey reported a wound infection rate of 3% in hospital that went up to 9% in community surveillance.23 However, Saggar et al. reported laparoscopic total extraperitoneal repair with mesh in a right-sided incarcerated inguinal hernia without any complications.24 We performed appendicectomy considering the young age of the patient.

 

CONCLUSIONS

Amyand’s hernia is a rare clinical entity that is difficult to diagnose pre-operatively clinically. The presence of an inflamed or gangrenous appendix increases the rate of complication, particularly increasing the rate of wound infection. Diagnosis is usually made at the time of surgery. Consequently, our recommendation is that the decision to perform an appendicectomy and/or to use mesh to repair hernias should always be individualised.

 

REFERENCES

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