|Year : 2021 | Volume
| Issue : 2 | Page : 287-289
A case report of amyand hernia and its management
Jayabal Pandiaraja1, Arumugam Shalini2
1 Department of General Surgery, Dr. Mehta Hospital, Chennai, Tamil Nadu, India
2 Department of Community Medicine, ACS Medical College, Chennai, Tamil Nadu, India
|Date of Submission||23-Jan-2021|
|Date of Decision||15-Sep-2021|
|Date of Acceptance||23-Sep-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Jayabal Pandiaraja
26/1, Kaveri Street, Rajaji Nagar, Villivakkam, Chennai - 600 049, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Amyand hernia is a variant of inguinal hernia with appendix as the content of the sac. Most of the Amyand hernia is undetectable in the preoperative period and mostly diagnosed during the intraoperative period. The management of Amyand hernia varies depends on the condition of the patient, and there are no standard guidelines for it. This case is reported for a few important educational points that pertain to Amyand hernia. Amyand hernia is one of the differential diagnoses for acute onset of pain in reducible inguinal hernia. Appendicectomy with hernioplasty can be done without complication in an inflamed appendix without much contamination.
Keywords: Acute appendicitis, acute inguinal pain, Amyand hernia, appendicectomy, mesh repair
|How to cite this article:|
Pandiaraja J, Shalini A. A case report of amyand hernia and its management. Arch Med Health Sci 2021;9:287-9
| Introduction|| |
Amyand hernia is a rare form of inguinal hernia where the content of the inguinal hernia sac is the appendix. The incidence of Amyand hernia is <1%, and it is more common in the pediatric age group rather than the adult. The nature of the appendix in the Amyand hernia can be normal, infected, and perforated. The treatment of Amyand hernia varies depends on multiple factors. Since the incidence of Amyand hernia is very low, there are no standard guidelines for the treatment of Amyand hernia.
| Case Report|| |
A 75-year-old male presented with a complaint of swelling in the right inguinal region for 6-month duration. He also said the pain in the right inguinal region for 2-day duration. There was no history of constipation or diarrhea. There was no history of bladder disturbances. There was no history of fever or malaise. The patient denied a history of chronic cough and contact with tuberculosis. There was no history of previous surgery. There was no prolonged drug intake for any chronic illness. On general examination, his pulse rate – 92/min, blood pressure – 140/90 mmHg, respiratory rate – 18/min, and temperature – afebrile. Local examination showed swelling in the right inguinoscrotal region measuring around 9 cm × 7 cm. He complained of tenderness while examining the inguinal swelling.
On ultrasound examination, the content of the right hernia sac in the bowel. The patient was prepared for open right inguinal hernioplasty. Sac was separated from the cord structures [Figure 1]. Sac was opened, and it showed appendix as a content [Figure 2]. The appendix was inflamed and adherent to the posterior wall of the sac. Adhesions were separated from the sac, and appendicectomy was done [Figure 3]. The sac was ligated and pushed inside the peritoneal cavity. Since there was minimal inflammation, Lichtenstein tension-free mesh repair is done using polypropylene mesh. Postoperatively, the patient recovered well without mesh infection or other complications. The patient was followed up for more than 24 months without any complications. Postoperative histopathology of the appendix confirmed the features of acute appendicitis [Figure 4].
|Figure 1: Intraoperative image shows right inguinal hernia with sac with cord|
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|Figure 2: Intraoperative cut open section of sac shows inflamed appendix|
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|Figure 4: Postoperative histopathology shows neutrophil infiltration along with congestion|
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| Discussion|| |
Most of the Amyand hernia is diagnosed during the intraoperative period rather than the preoperative period. This is due to hernia is diagnosed based on the clinical examination rather than imaging modality. Computed tomography is the best preoperative investigation of choice for Amyand hernia, and it is rarely done during the preoperative period. The clinical presentation of Amyand hernia is varied from asymptomatic to intra-abdominal sepsis. Acute onset of pain in the inguinal hernia is one of the clinical presentations of infected Amyand hernia apart from strangulated inguinal hernia. Infected Amyand hernia can be considered one of the differential diagnoses in a patient with acute onset of pain in the reducible inguinal hernia.
In the previous era, the most commonly recommended treatment for Amyand hernia is appendicectomy with the anatomical repair of the hernia defect. This is due to the fear of mesh infection and other complications related to appendicectomy. Now, there is a change of treatment algorithm for Amyand hernia due to better availability of antibiotics, more sterile surgical field, better macro porous lightweight mesh, availability of biological mesh, and laparoscopic surgery. Apart from the perforated appendix, normal and infected Amyand hernia can be managed by appendicectomy with hernioplasty.
According to Losanoff and Basson, Amyand hernia is classified into four types. Type I is a normal appendix that requires patch repair with or without appendicectomy. Type II is appendicitis which requires appendicectomy with bio patch repair or a simple repair. Type III is appendicitis with peritonitis which requires laparotomy and further management. Type IV is severe intra-abdominal sepsis that requires management according to the patient's condition [Table 1].
Since the incidence of Amyand hernia is rare, there is no randomized control trial or large studies to suggest the exact treatment plan for each stage of the disease. In the literature, there were two case reports by Ali et al. and Morales et al. suggested appendicectomy with mesh repair can be done safely in a patient with acute appendicitis without peritonitis. Apart from synthetic mesh, bio mesh is an acceptable alternative for Amyand hernia with appendicitis. There are pros and cons for the use of both meshes in Amyand hernia with appendicitis [Table 2]. The chance of mesh infection and removal is the complication by synthetic mesh, but there is no literature suggestive till now in Amyand hernia. The advantage of using biological mesh in Amyand hernia is less chance of infection and second surgery for mesh removal. However, there is a chance of high recurrence related to the biological mesh. The study by Sharma et al. showed less incidence of wound infection with proper perioperative antibiotics. Considering patient condition and the pros and cons of synthetic mesh, biological mesh, and anatomical repair, one can take the call regarding the type of repair.
| Conclusion|| |
Apart from obstruction, Amyand's hernia should be considered one of the differential diagnoses of acute onset of groin pain in the right inguinal hernia. Amyand hernia with acute appendicitis without abscess or necrosis, appendicectomy, with hernioplasty can be done. Preoperative ultrasound of the inguinal hernia is not accurate to predict Amyand hernia. Treatment of Amyand hernia is still not standardized due to the low incidence of disease occurrence. Treatment of Amyand hernia should be tailored according to the individual condition of the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]