Amyand's hernia in a patient with acute complicated diverticulitis. A case report and review of the literature

Abstract

Introduction

Amyand's hernia with an inflamed or perforated appendix is rare with incidence of 0.1 % and 0.01 % of cases respectively. It has been described in conjunction with cecal perforation, cholecystitis and ureterolithiasis. Yet, its association with acute sigmoid diverticulitis has never been reported before.

Presentation of case

A 57-year-old male presented to the emergency department with acute abdomen and an indurated right inguinal mass. A preoperative computed tomography (CT) scan reported a giant inflamed sigmoid diverticulum and an Amyand's hernia with a complicated appendicitis. The patient was taken to the operating room and a midline laparotomy incision was made. A giant sigmoid diverticulum with ischemic patches was encountered. The cecal appendix was found inside the right inguinal canal, with a perforation in its distal third. A Hartmann's procedure, appendicectomy and non-mesh inguinal hernia repair was accomplished.

Discussion

Case reports of Amyand's hernia in patients with simultaneous abdominal conditions are scarce. Symptoms in these patients could be various and may lead to preoperative imaging and diagnosis. In this case acute abdomen in physical examination demanded imaging analysis and a preoperative diagnosis of acute diverticulitis and Amyand's hernia with a perforated appendicitis was made.

Conclusions

Amyand's hernia with acute perforated appendicitis is a rare entity. CT scan is useful for diagnosis of Amyand's hernia and associated conditions. Preoperative diagnosis of Amyand's hernia and concomitant abdominal disease aids in the therapeutic approach and management. To our knowledge this is the first case report of an Amyand's hernia in a patient with acute diverticulitis.

Highlights

• •Amyand's hernia with a perforated appendix is very rare.
• •First case report in conjunction with acute diverticulitis.
• •Computed tomography scan is useful for preoperative diagnosis of Amyand's hernia and associated conditions.

1. Introduction

Amyand's hernia is a rare entity defined as an inguinal hernia sac containing a normal or inflamed appendix [1]. While present in 1 % of all inguinal hernia cases, an inflamed or perforated appendix is even rarer with an incidence of 0.1 % and 0.01 % respectively [2].

Diagnosis is predominantly performed intraoperatively due to its low incidence and variation of symptoms [1]. Imaging studies aid in preoperative diagnosis. Computed tomography (CT) findings describe a blind tubular structure within the inguinal hernia sac with or without periappendiceal fat stranding [1].

Amyand's hernia has been reported in conjunction with cecal perforation, left-sided cases with cecum and terminal ileum comprised, and even cholecystitis and ureterolithiasis [[3], [4], [5], [6]]. Yet, there is no report of Amyand's hernia in a patient with concomitant acute diverticulitis.

We present the case of a 57-year-old patient who presented to the emergency department with rebound tenderness in lower abdominal quadrants and an endured right inguinal mass. CT scan depicted acute diverticulitis and a complicated appendicitis with the appendix inside the right inguinal canal. This work has been reported in line with the SCARE criteria guidelines [7].

2. Case report

A 57-year-old male with past medical history of type 2 diabetes mellitus and hypertension presented to the emergency department with a 10-day history of generalized weakness, anorexia, myalgias, lethargy, dyspnea, right lumbar and diffuse abdominal pain which had increased in the last two days. On physical examination the patient presented with blood pressure of 140/90, heart rate of 115 beats per minute, respiratory rate of 30 per minute, temperature of 37 °C, and saturation of 80 % in pulse oximetry. Respiratory distress and diminished respiratory sounds were noted. The patient presented rebound tenderness on lower quadrants of the abdomen. Murhpy's and Giordano's signs were negative. Rectal test revealed and empty ampulla with no pain during examination. A painful, indurated mass located in the right scrotum was suspicious for an incarcerated inguinal hernia. Laboratory analysis showed leukocytosis of 13 × 10⁹/L, hemoglobin 12 g/dL, hematocrit count 38 %, platelet count 281, rest was normal.

A chest X-ray demonstrated a diffuse reticular interstitial infiltrate with a consolidation located in the inferior left lobe consistent with basal pneumonia. CT of the abdomen reported a giant sigmoid diverticulum with maximum with of 10.4 cm with fat stranding and pericolic inflammation classified as Hinchey Ia (Fig. 1). Moreover, the cecal appendix was described inside the right inguinal canal, with an enlargement of its distal segment, and fat stranding suggestive of an acute inflammatory process (Fig. 2).

Fig. 1.

Non contrast enhanced abdominal CT. Blue arrow shows a giant proximal sigmoid colon diverticulum, containing gas and feces. Fat stranding and pericolic inflammatory changes are seen surrounding the diverticulum. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2.

Non-contrast enhanced abdominal CT. A) and B) axial plane; blue arrow cecal appendix inside the right inguinal canal, enlargement of its distal segment, fat stranding and fluid, consistent with inflammatory process. C) Coronal reconstruction; green arrow shows right sided indirect inguinal hernia containing the cecal appendix and distal inflammatory process. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Patient was taken to the operating room and a midline infraumbilical laparotomy was performed. There was no contamination in the peritoneal cavity. A giant diverticulum of the sigmoid colon was firmly adhered to the abdominal wall and bladder. Multiple ischemic patches were encountered on the diverticular wall. Dissection of the sigmoid colon was achieved, and a Hartmann procedure accomplished.

The appendix was found inside the right inguinal canal with a perforation located at the distal third of the appendix (Fig. 3). Appendicectomy was performed with no complications. The peritoneal cavity was irrigated with saline solution and abdominal wall closed.

Fig. 3.

A) Cecal appendix inside the inguinal canal. B) Perforation in distal third of the appendix.

Posteriorly, an oblique incision in the right groin was made for hernioplasty. The hernia sac was resected, and spermatic chord elements preserved. Purulent discharge was seen in the inguinal canal and thus lavage and debridement were made. Hernia defect was repaired using a non-mesh Desarda technique. The incision was partially closed to avoid surgical site infection.

The patient had respiratory failure which precluded postoperative extubation. He was taken to the intensive care unit (ICU) for respiratory support. A chest CT scan described a pulmonary mass located at the posterior segment of the right lobe, with heterogeneous enhancement and mediastinal extension with pleural effusion suggestive of neoplastic origin (Fig. 4). The patient was treated postoperatively with broad spectrum antibiotics. Albeit treatment, the patient developed Acinetobacter baumanii in bronchial isolates. The patient developed organic failure and deceased after one month in the ICU.

Fig. 4.

Contrast enhanced thoracic CT. A) Arterial contrast phase blue arrow showing a pulmonary mass located at the right lower lobe, posterior segment, with heterogeneous enhancement and mediastinal extension. B) Bone filtered axial image; blue arrow shows lytic behavior of a soft tissue mass involving left pedicle, posterior vertebral body, and the adjacent left rib. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

3. Discussion

Acute appendicitis in a patient with Amyand's hernia is a rare clinical condition present in 0.1 % of inguinal hernia cases [1]. It has been reported in conjunction with cecal perforation, left-sided cases with cecum and terminal ileum comprised, and even cholecystitis and ureterolithiasis, yet, to our knowledge, there has not been a report of Amyand's hernia in a patient with acute sigmoid diverticulitis and so, no correlation between these entities has been described [[3], [4], [5], [6],8].

Case reports of patients with Amyand's hernia and simultaneous abdominal conditions are scarce (Table 1). Amyand's hernia and concomitant cholecystitis or ureterolithiasis, could present various symptoms such as right upper quadrant abdominal pain, or even right lumbar or diffuse abdominal pain [5,6]. Patients with concomitant Amnyand's hernia and Meckel's diverticulitis, Richter's hernia and fasciitis could present as a non-complicated reducible right inguinal hernia or as a potentially fatal septic shock [[9], [10], [11], [12]].

Table 1.

Amyand's hernia case reports with concomitant abdominal conditions.

Author (ref)	Year	Age	Sex	Symptoms	Signs	Preoperative Dx	Concomitant condition	Acute appendicitis	Tx
Mustafa [10]	2012	86	Male	Chronic right inguinal pain	Normal vital signs, soft abdomen, tender right inguinal hernia	No	Meckel's diverticulitis	No	Appendicectomy + ileum wedge resection + Lichtenstein
Tsalis [5]	2022	60	Male	RLQ, right lumbar and inguinal pain, right groin mass	Normal vital signs, reducible right inguinal hernia, Giordano +	Yes	Cholecystitis, ureterolithiasis	No	Ureteral stent + cholecystectomy + TAPP
Rajaguru [11]	2016	47	Male	Lower abdominal pain, pus from right inguinoscrotal area	Unstable, septic, tender abdomen, necrotizing fasciitis of right groin	No	Fournier	Yes	Right orchiectomy + debridement + appendicectomy + Bassini
O'connor [6]	2020	90	Male	RUQ, inguinal pain	RUQ tenderness, reducible right inguinal hernia	Yes	Cholecystitis	Yes	Conservative
Kuri [12]	2016	91	Female	Weakness, anorexia, lower abdominal pain, pus from right groin	Unstable, septic, soft abdomen, necrotizing fasciitis of right groin	No	Fasciitis, Richter's hernia	Yes	Appendicectomy + debridement + non-mesh repair
Sladek [9]	2019	70	Male	Lower abdominal pain, pus from right scrotum	Necrotizing fasciitis of right scrotum	No	Fasciitis	Yes	Appendicectomy + debridement

Dx: diagnosis, Tx: treatment, RLQ: right lower quadrant, RUQ: right upper quadrant, TAPP: transabdominal preperitoneal.

Decision to perform preoperative imaging is apparently associated with extraneous symptoms such as diffuse abdominal pain and acute abdomen mostly related to perforated appendicitis or concomitant intraabdominal conditions [2,13]. As in our case, our patient presented with diffuse abdominal pain and acute abdomen with rebound tenderness in lower quadrants which led us to perform preoperative imaging and ultimately diagnosis of complicated Amyand's hernia with concomitant acute diverticulitis was made. Inguinal ultrasound and CT scan have been reported as reliable adjuncts in the diagnosis of this entity. Typical CT scan findings consist of blind tubular structure with wall thickening, fat stranding and liquid in the hernia sac. CT scan aids in the exclusion of differential diagnosis in cases of diffuse or located abdominal pain [1]. In our case, a preoperative diagnosis of an acute diverticular process and an Amyand's hernia facilitated the surgical approach. A midline incision was planned for this reason. The diverticulum presented ischemic patches which required resection and a Hartmann procedure was accomplished.

The treatment of Amyands hernia depends on presence of acute appendicitis and abdominal sepsis as proposed in Losanoff and Basson's classification [14]. In this case, a type IV hernia was diagnosed and appendicectomy with a non-mesh hernia repair was done. A Desarda procedure, where external obliques fascia is used as reinforcement of the inguinal canal floor, was implemented. Desarda's technique has been reported to be comparable with Lichtenstein procedure where no differences in recurrence, chronic pain or foreign body sensation [15,16].

4. Conclusion

Amyand's hernia with acute perforated appendicitis is a rare entity. CT scan is useful for preoperative diagnosis of Amyand's hernia and associated conditions. A preoperative diagnosis of Amyand's hernia and concomitant abdominal disease aids in the therapeutic approach and management. Although not yet proven, Amyand's hernia in concomitance with acute diverticulitis and lung disease could elevate mortality rate. To our knowledge this is the first case report of an Amyand's hernia in a patient with acute diverticulitis.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Informed consent

An informed consent was sign by the patient.

Ethical approval

The study is exempt from ethical approval. Ethics clearance was not necessary for this case report given there was no deviation from standard of care and an observational analysis implemented. The patient had informed consent signed and confidentiality undertaken.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Study concept, data collection, data analysis, writing the paper.

Guarantor

Dr. Alberto Riojas Garza.

Declaration of generative AI and AI-assisted technologies in the writing process

None.

Conflict of interest statement

None.