Amyand's hernia and associated acute appendicitis: A case report

Abstract

Introduction

Amyand's hernia is incarceration of vermiform appendix within inguinal hernia. Amyand's hernia associated with acute appendicitis is rare.

Case presentation

A male in his 5th decade of life presented with enlarged right reducible inguinal scrotal swelling and each episode of incarceration relieved manually. Background history of a movement disorder. Ultrasound reported right inguinoscrotal hernia with bowel content but no obstruction seen with plain abdominal x-ray. Elective right open inguinoscrotal repair was done. Intraoperative findings included enlarged superficial ring, enlarged hyperemic appendix in indirect hernia sac adhering to caecum. After appendectomy, the sac was transfixed above caecum. Hernioplasty was done with a polypropylene, poliglecaprone 25, macroporous and partially absorbable mesh. Immediate post-operative period was uneventful. Last review at 7 months showed no complication.

Clinical discussion

About 1 % of inguinal hernias retain part or whole appendix. In Amyand's hernia, 0.07–0.13 % of appendix is more prone to trauma, impaired vascular supply, inflammation, and microbial multiplication. Index patient's appendix was inflamed and histology confirmed focal acute transmural inflammation and denudation of appendiceal epithelial walls. Mesh repair is generally contraindicated in appendicitis or ruptured appendix but no post-operative complication occurred in index patient up to 7 months after appendectomy via the hernia with mesh repair.

Conclusion

Amyand's hernia with acute appendicitis is rare. Though use of mesh during surgery is controversial, hernioplasty was done in index patient because of the predisposing history of a movement disorder and recurrence rate of herniorrhaphy.

Highlights

• •Incarceration of vermiform appendix within inguinal hernia is Amyand’s hernia
• •Amyand’s hernia with acute appendicitis diagnosed in an adult with a movement disorder
• •Mesh repair, generally contraindicated in the presence of appendicitis was done because of a predisposing history of a movement disorder and to avoid hernia recurrence. No post-operative complication especially mesh infection occurred up to 7 months afterwards.

1. Introduction

Amyand's hernia has been defined as the incarceration of the vermiform appendix within an inguinal hernia. The appendix within the hernia sac may become inflamed, infected, or perforated [1,2]. Preoperative diagnosis of this condition is usually difficult and usually diagnosed with a CT scan or as an incidental finding intraoperatively [3,4].

The physical stress or chronic constipation and cough often seen in some movement disorders can predispose to inguinal hernia [5,6].

To the best of our knowledge, Amyand's hernia associated with acute appendicitis is rare. The present case of Amyand's hernia and associated acute appendicitis is reported in line with the SCARE criteria [7].

2. Case presentation

A male in his 5th decade of life presented to the Emergency Department with 5 months of progressive worsening and enlargement of right reducible inguinoscrotal swelling with multiple episodes of incarceration and in each case relieved manually. There was no history of vomiting or abdominal pain. The temperature was 36.7 °C and the pulse rate was 74 bpm. Ultrasound reported a right inguinoscrotal hernia with bowel content and a plain abdominal x-ray ruled out bowel obstruction (Fig. 1). The man has a medical history of a movement disorder and was booked electively for the open right inguinoscrotal hernia repair. Preoperative laboratory investigations showed a WBC of 5000 cells/ μL and a neutrophil count of 64.6 %.

Fig. 1.

Plain abdominal Xray (supine view).

Intraoperative findings included an enlarged superficial ring, cord adhesion, indirect hernia sac, enlarged hyperemic appendix as sac content and caecum adhered to the sac wall (Fig. 2a). An appendectomy was done; the sac was transfixed above the caecum (Fig. 2b), and hernioplasty with a polypropylene, poliglecaprone 25, macroporous, and partially absorbable mesh.

Fig. 2.

Enlarged hyperemic appendix in the inguinal sac (Amyand's hernia) [a], and Caecum after appendectomy [b].

Histopathological gross examination of the appendix measured 7 × 1.5 × 1 cm and with a wall thickness of 4 mm while the histopathological sections of the appendiceal walls in Fig. 3 (a, b, c, & d) revealed inflammatory cells with prominent focal acute transmural inflammation and edematous focal denudation of the epithelia.

Fig. 3.

Histopathological sections of the appendiceal wall [a, b, c & d] with prominent focal acute transmural inflammation and edematous focal denudation of the epithelia.

The immediate postoperative period was uneventful and was last reviewed 7 months later at the Surgical Outpatient Department with no complaint.

3. Discussion

About 1 % of all inguinal hernias contain part or whole of the appendix. Amyand's hernia is the incarceration of the appendix within an inguinal hernia. The appendix may be healthy, ruptured, infected or inflamed [1,2,8].

It has been documented in patients aged 3 weeks to 92 years with a varying incidence from 0.19 % to 1.7 % and is thrice more likely to be diagnosed in children because of their patent processus vaginalis [9,10], more on the right side and in males [2]. When seen in females, it is more often in post-menopausal women [11]. The incidence of appendicitis within an Amyand's hernia is about 0.07–0.13 % [11]. This is due to the appendix being more prone to trauma, impaired blood supply, inflammation and bacterial multiplication [9,12].

In our study, the appendix was found to be inflamed, and confirmed by histology. The index patient had no complications of the appendicitis unlike those described in various literature such as perforation with abdominal abscess [9,13], inflamed testicle [9,14], necrotizing fasciitis of the inguinal region [9,15] or even death which has been documented to be within 14 to 30 % [2].

Amyand's hernia is generally an incidental finding at surgery as seen in the present case. Clinical presentations often include tender irreducible inguinal or inguinoscrotal mass which can be mistaken for a strangulated inguinal hernia [11,16]. The decision to remove the appendix remains the surgeon's choice as some authors have argued against appendectomy of a healthy appendix, that it may be harmful due to contamination of a clean procedure by transecting a fecal-containing organ or the compromise of the pediatric immune development following removal of the appendiceal lymphoid tissue [10,16]. Some other surgeons perform appendectomies on a case-by-case basis [17].

Generally, the use of mesh repair is contraindicated in appendicitis or ruptured appendix due to increased sepsis risk and is often followed by thorough abdominal and pelvic washouts [11]. Losanoff proposed a classification of Amyand's hernia with a treatment guide [18]. The patient in this case, despite being a class II, had appendectomy via the hernia with mesh repair and had no post-operative complication such as mesh infection up until 7 months post-op. A polypropylene, poliglecaprone 25, macroporous, and partially absorbable mesh was used for the patient. Also, for the patient with a predisposing factor of having a recurrence of inguinal hernia due to his movement disorder, the recurrence rate when a mesh repair is done is 3 % [19].

4. Conclusion

The incidence of Amyand's hernia associated with acute appendicitis remains rare and the decision to use mesh or not during the surgery is controversial. In the index patient, hernioplasty was considered because of an inguinal hernia predisposing history of a movement disorder and to avoid the recurrence of the inguinal hernia.

Author contribution

Somadina Ikpeze: Study design, concept, manuscript drafting.

Ikenna Chimuanya Ohiaeri: Literature review and data collection.

Oleksandar Bondar: Supervising and case report analysis.

Nkemdilim Kenechukwu Onyia: Literature review, manuscript writing and clinical picture.

Muhammad Saqib: Literature review and manuscript writing.

Johenis Creagh Garcia: Histology slide narration and manuscript writing.

Patient consent

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

Ethical approval

Ethical approval for this study was provided by the Health Research and Ethics Committee of Seychelles Hospital, Seychelles on November 19, 2024.

Guarantor

Somadina Ikpeze.

Research registration number

Not applicable.

Funding

None.

Declaration of competing interest

None.