Intraoperative diagnosis of Amyand's hernia, a case report

Abstract

Introduction

Hernia forms when an organ or its fascia protrudes through the continuing cavity's wall. Amyand's hernia describes an inguinal hernia containing an appendix, regardless of inflammation.

Presentation of case

Our patient was complaining of an increasing lump in the inguinal area. It started 5 years ago as a small mass that gradually increased, manifesting distressing symptoms. The initial diagnosis was an indirect right inguinal hernia. During the surgery, the presence of an indirect inguinal hernia was observed, and the appendix was revealed within the sac, with the observation of adhesion of the appendix tip to the sac.

Discussion

Amyand's hernia describes an inguinal hernia, containing the appendix inside it. It is classified according to Losanoff and Basson depending on the presence and spread of inflammation. The diagnosis of Amyand's hernia is often made during the surgery because of its rarity and unspecific symptoms. When symptoms and signs occur, they masquerade as strangulated hernia rather than appendicitis.

Conclusion

Even Amyand's hernia is a rare condition; it should be a differential diagnosis in patients who come with strangulated hernia or appendicitis. More studies are needed to understand the physiology of this type of hernia. In addition, more cases should be reported to help establish guidelines for diagnosing and treating this hernia.

Highlights

• •Even Amyand's hernia is a rare condition; it should be a differential diagnosis.
• •More studies are needed to understand the physiology of this type of hernia.
• •More cases should be reported to help put guidelines in place for diagnosis and treatment.

1. Introduction

Hernia forms when an organ or its fascia protrudes through the continuing cavity's wall [1]. Inguinal hernias are a common type, occurring in 27–43 % of men and 3–6 % of women [2]. Amyand's hernia (AH) describes an inguinal hernia containing an appendix inside it, regardless of inflammation [[2], [3], [4]]. Claudius Amyand is the first surgeon who described and treated it in 1735 [5]. It is a rare type, representing only 1 % of all inguinal hernias [3]. It is more common in males (90 % of patients), and on the right side because of the normal location of the appendix and the increased inguinal hernia in the right side [[2], [3], [4]]. This hernia is often asymptomatic; in some cases, it presents as incarcerated or strangulated hernia or acute appendicitis [6]. Therefore, it is difficult to diagnose it before surgery [2]. In this paper, we present a rare case of AH to share our clinical insights and encourage more studies about this unique condition. This work has been reported in line with the SCARE criteria [7].

2. Case report

A 76-year-old male presented to our hospital, complaining of an increasing lump in the right inguinal area. It started 5 years ago as a small mass that gradually increased in size, manifesting distressing symptoms including sharp pain, along with sensations of heaviness and pressure in the inguinal area, exacerbated during prolonged physical activity. The patient's surgical history revealed a left inguinal hernia repair. Medical, familial, drug, and psychosocial histories were unremarkable. Clinical evaluation revealed a large reversible inguinal hernia protruding notably during standing, coughing, increased abdominal pressure, and reduced in a recumbent position. The physical examination of other systems was within normal. The diagnosis depending on clinical manifestations and examination was indirect right inguinal hernia. The patient underwent laboratory tests and consultations before surgery, and they were all within normal. During the surgery, which was done by a specialist, the presence of an indirect inguinal hernia sac was observed coursing alongside the spermatic cord. It was isolated from the cord and opened for examination of its contents, revealing the appendix within the sac, with observation of adhesion of the appendix tip to the inner wall of the sac (Fig. 1, Fig. 2, Fig. 3). Adhesiolysis of the appendix was performed, followed by its excision, ligature of the hernia sac, and subsequent excision, along with concurrent repair of the inguinal hernia utilizing the Lichtenstein technique. The patient was discharged from the hospital after 2 days without any complications. The follow-up for six months was within normal.

Fig. 1.

image from surgery, showing the appendix inside the hernia sac.

Fig. 2.

image from surgery, showing the appendix inside the hernia sac.

Fig. 3.

image from surgery showing the appendix during its excising.

3. Discussion

AH describes an inguinal hernia, containing the appendix inside it, regardless of the inflammation [4]. It is classified according to Losanoff and Basson depending on the presence and spread of inflammation (Table 1) [6]. Many theories try to explain the pathology of AH, one of them suggests that it may be a congenital situation as there are studies that describe a fibrous connection between the right testis and appendix with the presence of patent processus vaginalis, this connection can lead to the appendix towards the hernia sac; the presence of this hernia in the neonates and premature twins supports this theory. Left AH has been described in patients with intestine malrotation, situs inversus, and mobile cecum [4]. Many causes explain appendicitis in AH including (1) the extraluminal obstruction due to the pressure on the hernia neck, the abdominal muscles' contraction, and any agent can increase the intraabdominal pressure; which leads to cut off the blood supply and increase the bacterial growth later, (2) vulnerability to trauma during migration (3) adhesions form between the appendix and internal sac wall, resulting in forming irreducible hernia, which is prone to external trauma [1,2,8]. The diagnosis of AH is often made during the surgery because of its rarity and unspecific symptoms [9]. When symptoms and signs occur, they masquerade as strangulated hernia rather than appendicitis, including groin pain, nausea and vomiting, irreducibility, and tenderness [6]. In acute cases, the patient complaints of sudden-onset pain in the epigastrium or periumbilical region with tenderness in the right lower quadrant, combined with tender irreducible mass in the inguinal or inguinoscrotal region [1]. In addition to AH, many differential diagnoses should be in our minds such as irreducible, incarcerated or strangulated hernia, acute appendicitis, strangulated omentocele, testicular tumor with hemorrhage, torsion of the testis, Richter's hernia, inguinal adenitis, acute hydrocele, and epididymitis [2,8]. Even the final diagnosis is made during surgery; many methods may help us such as laboratory tests (elevated white blood cells and CRP differentiate inflamed appendix from healthy one), ultrasound imaging (shows non-compressible, blind-ended, cecum-linked tubular structure in the hernia sac), and computed tomography (CT) scanning, which is considered the preferred method; it allows us to see the appendix directly in hernia type 1, but in types 2 and 3, we Can see thickened appendix, fat stranding, fluid collections or abscess because of the inflammation process [2,9]. Diagnostic laparoscopy is also recommended as a diagnostic method. The management of AH is depending on its classification (Table 1) [3]. The appendectomy in type 1 hernias is still controversial, some surgeons support routine appendectomy, while others refuse it as many researches show that removing the appendix may affect the immune system development in children. The treatment of Left-sided type 1 AH contains appendectomy to avoid future diagnostic problems [2]. In our case, we observed during the surgery that the tip of the appendix linked into the inner wall of the sac, which supports the presence of an inflammatory process, so an appendectomy was done. The complications of AH include periappendicular or appendicular abscess, appendicular perforation, intra-abdominal abscess, necrotizing fasciitis of the anterior abdominal wall, scrotal fistula, and local thrombosis rarely [4].

Table 1.

the classification and management of Amyand's hernia depending on Losanoff and Basson classification.

Type	Description	Management
I	Inguinal hernia containing normal appendix.	Hernia reduction, mesh repair.
II	Inflammatory changes during the hernia sac without an abdominal sepsis.	Appendectomy, non-mesh hernia repair.
III	Findings in type III with an abdominal or abdominal wall sepsis.	Laparotomy, appendectomy, non-mesh hernia repair.
IV	Inflammatory changes during the hernia sac with serious and complicating pathology in the abdominal cavity.	As type 3 management + management of the concomitant abdominal disease.

4. Conclusion

AH should be in our minds as differential diagnosis in patients come with strangulated hernia, appendicitis, and acute abdomen. Even the complications of this type of hernia are rare, but they are dangerous and life-threatening. Therefore, fast and accurate diagnosis and treatment are essential. More studies are needed to understand the physiology of this rare type of hernia and to determine the best diagnosis and treatment methods.

Consent for publication

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

Ethical approval

Not applicable because the article does not include any personal information.

Funding

There are no sources of funding.

Author contribution

Kenana Tawashi

First author, corresponding author

Oncologist resident, Al Bairwni Hospital, Damascus University, Damascus, Syria

Stemosis for Scientific Research, Damascus, SYR

00963943363600

tawashikenana@gmail.com

Eva khalouf

Second author

Faculty of Pharmacy, Damascus University, Damascus, Syria

Stemosis for Scientific Research, Damascus, SYR

Evakhalouf99@gmail.com

MUHANNAD DEBES WZET

Second author

Faculty of Medicine, Damascus University, Damascus, SYR

Stemosis for Scientific Research, Damascus, SYR

mohannaddbs@gmail.com

Olga Bittar

Second author

Faculty of Medicine, Aleppo University, Syria

Stemosis for Scientific Research

olgaalbitar1996@gmail.com

Guarantor

Kenana Tawashi.

Research registration number

N/A

Declaration of competing interest

There are not any conflicts of interest.

Availability of data and materials

Not applicable.