Amyand's hernia in an elective inguinal hernia repair: A case report

Abstract

Introduction and importance

Amyand's hernia is a rare condition in which the appendix is situated inside an inguinal hernia sac. It occurs in less than 1 % of all inguinal hernias, and preoperative diagnosis is often challenging, even with the aid of ultrasonography or computed tomography. The course of treatment depends on the degree of inflammation of the appendix. In this report, we present a case of Amyand's hernia that was discovered during elective inguinal hernia repair.

Case presentation

We are presenting a case of a 65-year-old man who complained of right inguinal swelling and pain for one week. Upon clinical examination, a nontender and reducible mass was discovered in his right inguinal region. Further ultrasound examination suggested the presence of a right inguinal hernia, without any additional notable findings. During the surgery, the appendix was found to be present inside the indirect inguinal hernia sac, and due to its normal condition, the hernia was reduced, and a prosthetic mesh was placed.

Clinical discussion

Amyand's hernia is a rare form of inguinal hernia, predominantly found in men, with the appendix being trapped within the inguinal canal. The clinical presentation and treatment depend on the appendix's inflammation, and while ultrasonography is commonly used for diagnosis, preoperative detection of Amyand's hernia is often challenging.

Conclusion

Amyand's hernia is a rare but potentially life-threatening condition. A high index of suspicion is required to make the diagnosis. Surgical intervention is the treatment of choice, and In the absence of complications, the prognosis is favorable.

Highlights

• •Amyand's hernia is a rare condition in which the appendix is inside an inguinal hernia sac.
• •Preoperative diagnosis of this condition is often challenging, even with imaging aids.
• •Surgical intervention is the treatment of choice for Amyand's hernia, and the prognosis is favorable in the absence of complications.
• •The presented case involved a 65-year-old man with a nontender and reducible mass in his right inguinal region.
• •The appendix was found inside the indirect hernia sac, and the hernia was reduced and a prosthetic mesh was placed.

1. Introduction

The presence of appendix inside the inguinal hernia sac is an intriguing intraoperative finding during hernia surgery. As Claudius Amyand was the first surgeon who described a successful appendectomy during a hernia surgery, this entity is named after his honor [1]. The occurrence of this type of hernia is estimated to range from 0.19 to 1.7 % of inguinal hernia cases [2,3]. While the classification of Amyand's hernia (AH) was once considered impractical, it has become increasingly important with the use of synthetic mesh repair for inguinal hernias. The presence of acute appendicitis contraindicates the use of synthetic materials and presents a challenge for surgeons during the operation [3]. Additionally, the preoperative diagnosis of this type of hernia can be difficult in many cases. Therefore, it is now crucial to have prior knowledge of this condition in order to manage it effectively.

In this report, we describe a case of right inguinal Amyand's hernia in an elective hernia repair surgery who had a normal appendix. Also, this document has been composed in accordance with the SCARE criteria [4].

2. Case presentation

A 65-year-old man with a five-year history of bulging in the right groin, presented to the clinic, complaining the recent enlargement of the bulging and new-onset pain. The patient had no prior medical issues, including abdominal surgeries. During the physical examination, it was discovered that the patient had an indirect inguinal hernia when performing the Valsalva maneuver. Moreover, abdominal ultrasonography showed a reducible inguinal hernia with a 1.5 cm defect that included bowel loops. Due to the patient's health condition and preference, open surgical repair was recommended, and he scheduled for an elective tension-free open repair.

After spinal anesthesia in supine position and prep and drape, an oblique incision was made parallel to the inguinal ligament, and external oblique aponeurosis was separated caudally and cephalad. The spermatic cord was elevated carefully and encircled with a soft plastic tube. The indirect hernia sac was located on the medial aspect of spermatic cord, and after meticulous dissection, a large sliding hernia, including the appendix, was detected (Fig. 1). The hernia sac opened carefully, and the appendix grasped by a Babcock forceps to evaluate the condition of the appendix. Regarding the normal appearing appendix, the hernia reduced into the abdominal cavity, and the internal ring tightened using absorbable braided PDS 2.0 suture materials. Then, a synthetic polypropylene mesh was placed utilizing Lichtenstein technique. Then the external oblique muscle sutured. Scarpa's fascia and subcutaneous tissue were brought together with absorbable sutures, and the skin was repaired by subcuticular suturing. The patient was discharged after 1 2 h with no specific problems, and follow-up visits did not reveal any complications such as seroma or infection.

Fig. 1.

Intraoperative photograph showing a noninflamed appendix inside the hernia sac.

3. Clinical discussion

As previously mentioned, Amyand's hernia is a rare occurrence, accounting for less than 1 % of all inguinal hernia cases. A recently conducted systematic review showed that AH is more prevalent in men (87.6 %). While left-sided AH has been reported in the literature, the vast majority of AH cases occur on the right side [1,5]. The exact pathophysiology of AH is not well understood. Regarding that AH is a subtype of sliding hernias, we can hypothesize its cause with anatomic rationalization. Anatomically, the cecum can be fused with the lateral edge of the peritoneum in some individuals, while in others, it can be freely elevated within the abdomen. After the enlargement of hernia defect, increased intrabdominal pressure forces the lateral peritoneal edge (including the adhered cecum and the appendix) to pass through the inguinal canal. This repetitive movement of appendix within the inguinal canal, along with the patient's self-manipulation, may irritate the appendix and cause some degree of inflammation on it.

Clinical manifestation and treatment of AH depends on the extent of inflammation in the appendix. When a normally appearing, vermiform appendix is discovered during elective surgery, it usually does not present with any notable symptoms. However, an inflamed appendix can become stuck inside the inguinal canal, which can result in an incarcerated hernia, fecal spillage, and abdominal sepsis [6]. Imaging techniques used to diagnose AH include ultrasonography and computed tomography (CT). Since CT is typically not performed in non-emergency hernia cases, ultrasonography is a valuable imaging modality for diagnosing AH [7]. However, in many cases like ours, ultrasonography is not able to diagnose AH Preoperatively [8]. Therefore, the treatment of AH varies based on intraoperative findings. Losanoff classified AH into four subtypes, and mesh placement is not recommended in cases involving appendicitis (Types 2–4). Patients with any type of appendicitis should undergo appendectomy and their hernia repaired with natural tissue repair techniques. However, if appendicitis is not present, the appendix should be reduced into the abdomen and prosthetic mesh can be placed on the inguinal hernia canal (Type 1) [9]. In this report, since a normal appendix was encountered, it was classified as Type 1 AH. An in-depth analysis of the impact of early and accurate preoperative diagnosis of Amyand's hernia on patient outcomes, healthcare costs, and hospitalization durations could highlight the benefits of refining diagnostic algorithms and promoting timely interventions. Exploring minimally invasive surgical techniques and their outcomes in the context of Amyand's hernia could offer insights into potential advancements in surgical approaches, potentially leading to reduced postoperative complications and faster recovery times.

4. Conclusion

Thorough intraoperative examination of appendix via hernia incision will guide the surgeon to make the right decision. Normal vermiform appendices can be reduced safely, and placement of prosthetic mesh is recommended in patients without appendicitis.

Sources of funding

The authors didn't receive any financial support for this report.

Ethical approval

Ethical approval for this study (IR.SBMU.RETECH.REC.1402.216) was provided by the Research Ethics Committees of Vice-Chancellor in Research Affairs - Shahid Beheshti University of Medical Sciences, Tehran, Iran on 2 June 2023.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

CRediT authorship contribution statement

Kasra Hatampor, wrote the manuscript; Amir Zamani, Roozbeh Shadidi Asil provided the data; Manoochehr Ebrahimian co-wrote and supervised the paper.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Guarantor

Manoochehr Ebrahimian.

Registration of research studies

Not applicable.

Declaration of competing interest

The author declared no potential conflict of interests with respect to the research, authorship, and/or publication of this article.