Amyand's hernia presenting as chronic scrotal sinus

Abstract

A rare case of Amyand's hernia in an infant who presented with chronic discharging scrotal sinus is reported.

INTRODUCTION

The presence of vermiform appendix, whether inflamed or not, inside a hernia sac is called as Amyand's hernia. This rare condition constitutes 1% of all the inguinal hernias, whereas inflamed appendix is found in only 0.1% of the cases.[1] In pediatric patients, it can be mistaken for incarcerated/strangulated hernia, torsion of testis, or scrotal abscess.

CASE REPORT

A 1-year-old male child presented with a discharging sinus over the right hemiscrotum since the age of 3 months [Figure 1]. The child had a history of scrotal abscess, which got burst spontaneously, followed by intermittent episodes of pus discharge. The right spermatic cord was thickened and tender. An impulse on cry was present suggestive of inguinal hernia. The sinus could not be cannulated. The ultrasound of the right inguinoscrotal area revealed bowel herniation. A diagnosis of inguinal hernia with some bizarre congenital fistula was made. On inguinal exploration, there was a sliding hernia with cecum and appendix herniating into the sac. Grossly the appendix appeared to be edematous. It was densely adherent to the scarred sinus in the upper scrotum [Figure 2]. The right testis was slightly bulky and spermatic cord was thickened. The appendix adherent to the scrotal sinus was dissected. Appendicectomy followed by herniotomy was done. The postoperative period was uneventful and the child is asymptomatic at 1-year followup. Histopathology of the appendix revealed acute inflammation.

Figure 1.

Scrotal sinus

Figure 2.

Sliding hernia with herniation of cecum and the appendix. Appendix separated from the scrotal sinus

DISCUSSION

Amyand's hernia, although rare, is a well-known entity. It has been classified according to the degree of inflammation of appendix: (a) noninflamed, (b) inflamed, or (c) perforated appendix.[2] In a largest series of 30 cases of Amyand's hernia in children reported by Kaymakci et al.,[3] the incidence of the condition was reported as 0.42%, whereas that of inflamed appendices as 0.07%. Preoperative diagnosis of this condition is difficult. Although rare, the possibility should always be kept in mind in cases of acute scrotum. It may be mistaken for incarcerated/strangulated hernia, or torsion of testes. Various reports of incarcerated inguinal hernia with fecal discharge have been reported in the literature.[4,5] Interestingly, the boy for whom the first appendicectomy was done by Claudius Amyand also had scrotal fistula.[6] Sliding appendiceal inguinal hernia in children is even more rare.[7,8] Preoperative diagnosis in this condition is rare. Although not frequently used, ultrasound and computed tomography can be helpful in diagnosing such cases.[9] The condition should be strongly suspected when there is finding of tender hernia without radiologic or clinical signs of obstruction.[10]

The surgical options for tackling the appendix in an Amyand's hernia depend on the mode of presentation. Reports of larger series of Amyand's hernia in pediatric patients concludes that the presence of a normal appendix does not require appendicectomy, whereas acute appendicitis necessitates appendicectomy within the hernial sac.[3,11,12]

Complications, such as wound infection, epididymitis, and urinary retention have been reported. Recurrence of the hernia is always a possibility, especially in the cases of perforated appendix, appendicular abscess, and after surgical site wound infection. Mortality varies between 14% and 30%; risk being mostly associated with perforated appendix with or without periappendicular abscess formation and peritonitis.[4] The clinical awareness and strong suspicion of this entity can prevent the associated morbidity and mortality.