Amyand’s Hernia: Case Report and Therapeutic Strategy

Amyand’s hernia is defined as an inguinal hernia, containing the appendix within the hernia sac.[1] Incidence of this rare condition rises up to 1% (0.19–1.7%) of all inguinal hernia cases.[2] Inflammation of the appendix within the inguinal sac is even rarer, as it corresponds to 0.1% (0.07–0.13%) of all Amyand’s hernia cases.[3]

Keywords:Amyand hernia; Appendicectomy; Inguinal Region

A 60 year old male presented to the emergency department with a history of right lower quadrant pain, and complaint of a pain and swelling in the right inguinal region for the past three weeks that increased gradually in size. Physical examination included an indirect right inguinal hernia incomplete, and reductible type with positive cough impulse. Patient was diagnosed as indirect inguinal hernia. We made a preoperative diagnosis of right inguinal hernia and we planned a hernia mesh repair. During surgery, the hernia sac contained the appendix. The appendix was totally normal, not congested, not inflamed, and there were adhesions with the sac so the adhesiolyses was difficult and we didn’t make the appendicectomy. The patient postoperatively received fluid therapy, and antibiotherapy and was discharged on postoperative day 2.

Amyand hernia is an inguinal hernia that contains the appendix within the hernia sac. Amyand described the first case of incarcer- ated inguinal hernia containing a perforated appendix in a 11 year old boy in 1735. [4]

A ligation of the hernia and appendicectomy were performed simultaneously.

This hernia should’nt be confused with De Garengeot hernia after René Jacques croissant de Garengeot, who described in 1731 a case of fermoral hernia that contains a non-inflamed appendix. [5]

Physical examination will often reveal swelling in the right groin, pain and tenderness. Other symptoms may appear like fever, vomiting, and different gastrointestinal symptoms, depending on appendix’s situation : normal, inflamed, perforated or gangre- nous. [6]

CT scan shows a direct visualization of the appendix inside inguinal canal. [7] The pathogmnomonic sign for Aymand’s hernia is a blind ending tubular structure inside the hernia sac, arising from the base of the cecum, wall thickening, hyperemia and periappen- diciceal fat stranding.[8] Indirect sign of Amyand’s hernia can be the proximity of coecum to the hernia sac. [9]

Losanoff and Basson proposed a classification for Amyand’s hernia, setting a therapeutic framework.[10] Singal et al. refer to the modification of the Losanoff and Basson classification of Amyand’s hernia, also known as Rikki modification. [11] A fifth type of Amyand’s hernia were added, referred as an incisional hernia through which the vermiform appendix protrudes.

This type is divided into three subtypes, 5a, 5b and 5c.[12]

As a general rule : in case of a non-inflated appendix, we do the hernia repair without the appendicectomy. [13]

Some researches believe that realizing the appendicectomy could decrease post-operative complications by converting a clean surgery to a clean-contaminated one.[14] Besides, surgical manipulations in the base of the caecum during appendicectomy could increase the recurrence rate of the inguinal hernia.[15] Left-sided Amyand’s hernia is the exception to this rule, because preventive appendicectomy is recommended, as in a case of a future appendicitis, there could be a high risk of false diagnosis. [16]

Therefore, the decision should be based on common sense, patient’s age, life expectancy, life-long risk of developing acute appen- dicitis, and the size and overall anatomy of the appendix.[17]

Using protehetics material in inflamed, suppurative, or perforated appendicitis is strongly not recommended because of the in- creased risk of surgical site infection. [18]