Emergency totally laparoscopic surgery for appendicitis in right Amyand's hernia associated to symptomatic left inguinal hernia: A case report

Abstract

Introduction and importance

Amyand's hernia is a rare type of inguinal hernia which contains vermiform appendix in the inguinal sac, seldom complicated by acute appendicitis. It is usually repaired by open inguinal approach, but laparoscopic technique has been increasingly described in literature; nevertheless, standard of care is far from being defined. Here we report the case of Amyand's hernia complicated by acute appendicitis and simultaneous symptomatic left inguinal hernia, both repaired by laparoscopic technique.

Case presentation

A 85-years-old man presented with acute appendicitis in Amyand's hernia and simultaneous incarcerated left inguinal hernia.

Clinical discussion

After complete preoperative work-up, the patient underwent laparoscopic appendectomy and laparoscopic bilateral hernia repair with mesh.

Conclusion

Laparoscopic approach may be safe and feasible for Amyand's hernia treatment in emergency setting when performed by expert hands, with minimized risk of surgical site infection (SSI), quick recovery and reduced hospital stay. Laparoscopic hernia repair with mesh can be a reasonable approach in selected cases of bilateral or recurrent hernia, and concomitant intrabdominal inflammation, especially when contamination is scarse and limited to a restricted area.

Highlights

• •We present the case of laparoscopic management of Amyand’s hernia in emergency setting. Through abdominal toilette after appendectomy and simultaneous inguinal hernia repair, carried our by laparoscopy during the same procedure, may give patient the advantages of both procedures in a single stage
• •Laparoscopic approach of Amyand’s hernia complicated by acute appendicitis should be performed by expert hands
• •Minimized risks of surgical site infection, quick recovery and reduced hospital stay are the main benefits of this approach, especially useful in case of elderly patients with comorbidities.

1. Introduction

Amyand's hernia, first described in 1735, is a rare condition defining the presence of the vermiform appendix in the inguinal hernia sac. It counts for 1 % of inguinal hernias, and less than 0.1 % of them is complicated by acute appendicitis [1]. Clinical presentation is similar to an incarcerated hernia. Recent papers report the use of laparoscopy for diagnosis and repair of Amyand's hernia, but to date there's no evidence supporting minimally-invasive approach as technique of choice for its surgical management [2]. We report the case of Amyand's hernia complicated by acute appendicitis and symptomatic left inguinal hernia, which were both treated by laparoscopic approach in one stage in emergency setting, using bilateral mesh, with uneventful postoperative course.

2. Case presentation

A 85-year-old male patient was admitted to our emergency department with a painful non reducible right inguinal mass, associated with vomit and constipation since two days before; he was afebrile (temperature 36.5 C), with normal vital signs. The patient underwent right inguinal hernia repair by Lichtenstein's technique ten years before.

Manual reduction of the right inguinal mass was unsuccessful. Laboratory tests showed mild leukocytosis (WBC 10.93 × 10^3/μl); contrast-enhanced CT-scan of the abdomen demonstrated a dilated appendix with appendicolith trapped in the right inguinal canal, and periappendiceal fat stranding (Fig. 1A-B).

Fig. 1.

A-B Acute appendicitis in Amyand's hernia.

Diagnostic laparoscopy revealed an inflamed appendix incarcerated in the right inguinal internal ring (Fig. 2): therefore, radiological suspicion of Amyand's hernia was confirmed.

Fig. 2.

Amyand's hernia: intraperitoneal view.

After laparoscopic lysis of adhesions, the appendix was reduced in abdominal cavity. During the maneuvers, polypropilen mesh used in previous Lichtenstein's procedure was partially dislocated and consequently removed (Fig. 3). The hernia sac was checked, no residual components were observed (Fig. 4). Incarcerated left inguinal hernia with sigmoid colon was also present: we proceeded with lysis of adhesions and hernia sac reduction. We performed thorough washing of peritoneal cavity and decided to perform bilateral TAPP (Fig. 5).

Fig. 3.

Past mesh dislocated in abdomen.

Fig. 4.

Reduction of the left sac.

Fig. 5.

Left TAPP: detail on trasversalis fascia's closure.

3D Max mesh (Bard) was used for both hernias, fixed with fibrin glue; then, we closed peritoneal flaps with running-suture in V-Lock 3/0. Lastly, we performed laparoscopic appendectomy using two PDS endo-loops (Fig. 6).

Fig. 6.

View before appendectomy.

Pathological examination of the specimen confirmed acute appendicitis with fecalith obstruction. Postoperative course was uneventful and the patient was discharged on POD 4. He underwent outpatient control 10 days after discharge: he referred no pain neither fever, with regular bowel movements; furthermore, no signs of surgical site infection were observed.

3. Discussion

Losanoff and Basson's classification system of Amyand's hernia recognizes four subtypes, each one treated differently, mainly by open approach [1]. Vermillion et al. reported the first laparoscopic reduction of Amyand's hernia in 1999. The acute inflamed appendix was removed laparoscopically, followed by an elective Lichtenstein repair [2]. Mullinax et al. reported a case with simultaneous laparoscopic appendectomy and inguinal hernia repair [4]. Literature reports several surgical methods, but the standard surgical care isn't defined yet. In particular, controversy exists whether or not to use a mesh when Amyand's hernia is complicated by inflamed or perforated appendix. Transabdominal laparoscopic approach has the benefit of easier mobilization of appendix into abdominal cavity and less weakening of inguinal canal components, since hernia defect and sac are carefully handled [3]. This approach provides also the advantage of better visualization and management of the whole appendix, from tip to base, while sac can be reduced safely under direct visualization [3]. Laparoscopy may also reduce adhesion formation, facilitating a second stage laparoscopic hernia repair as a feasible option. Moreover, faster recovery and better cosmesis are expected, compared to open anterior approach.

Keeping in mind the aforementioned experiences reported in literature, we proposed a total laparoscopic strategy for Amyand's hernia in emergency setting, because the patient had a bilateral hernia defect, the right one was a recurrent hernia with a previous anterior correction and, last but not least, the intra-abdominal contamination was scarce.

4. Conclusion

We report this rare case of Amyand's hernia to enlighten that full-laparoscopic approach (e.g. diagnostic laparoscopy, bilateral mesh hernioplasty, appendectomy) is safe and feasible also in emergency setting. Authors highlight that both surgeons had extensive training in abdominal wall surgery, with proctored high-volume training, and the general surgery unit is recognized as Referral Center for Abdominal Wall Surgery according to Italian chapter of European Hernia Society (I.S.H.A.W.S.) criteria for certification [5].

This approach aimed to provide several advantages to this old patient, who was suffering pain for both appendicitis and subocclusive symptoms caused by bilateral hernia. We can desume that a thorough abdominal toilette after the appendectomy and a correct defects closure in hernia repair can provide the advantages of both procedures in a single stage.

5. Methods

The paper has been written according to SCARE criteria [6]. Consent to the processing of data for scientific purposes is requested and signed at the time of admission and kept in the medical record; the authors confirm that the patient's parents have signed consent to the publication of the data.

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.

Ethical approval

In our institute, the approval of the ethics committee for the retrospective analysis of a clinical case report is not required.

Funding

No fundings were used.

Author contribution

William Sergi: design of work and manuscript writing

Annarita Libia: co-author

Ambra Chiappini, Stefano D'Ugo: data collection

Stefania Romano, Marcello Spampinato: supervisors

Guarantor

Marcello Spampinato.

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Provenance and peer review

Not commissioned, externally peer-reviewed.

Conflict of interest statement

The authors declare no conflict of interests.