-Hernia (2003) 7: 89-91DOl IO: 1007Is 10029-002-0098- 5

CASE REPORT

C. D'Alia' M.G. Lo Schiavo' A. TonanteF. Taranto . E. Gagliano . L. BonannoG. Di Giuseppe' D. Pagano' G. Sturniolo

Amyand's hernia: case report and review of the literature

Received: 22 May 20021 Accepted: 6 August 20021 Published online: 15 January 2003© Springer- Verlag 2003

Abstract The authors report a case of gangrenousacute appendicitis in the sac of an inguinal hernia(Amyand's hernia). After a review of the literature,they emphasise the extreme rarity of the c~se rep?r~ed,they underline how the clinical picture IS highly sirnilarto that of a strangulated inguinal hernia. They affirmthat appendicectomy and hernioplasty ~ay beperformed at the same time, si~ce the repair ?f .thehernia should be performed without prosthesis im-plantation due to the contamination of the operatingfield.

Keywords Hernial appendicitis . Orchidectomy .Appendicectomy . Hernioplasty . Diagnosis

Introduclion

An inguinal hernia whose sac contains an acute appen-dicitis is defined as "Amyand's hernia", in homage toClaudius Amyand, an English surgeon of the 18th cen-tury, who was the first to describe a case of acuteappendicitis in a hernial sac in a child of Il [Il

We present a case of this extremely exceptional con-dition observed once in 1,341 inguinal hernia operationsperformed over the last 13 years.

C. D'Alia (181) . M.G. Lo Schiavo' A. Tonante' F. TarantoE. Gagliano· L. Bonanno . G. Di GiuseppeD. Pagano' G. Sturniolo .. .Dipartimento di Discipline Chirurgiche Generali e Speciali,V.O. di Chirurgia Generale VI,Universita' degli Studi di MessinaE-mail: cdalia@unime.itTe!.: + 39-090-2212611Fax: + 39-090-693661

Present address: C. D'AliaVia San Domenico Savio is. 255/B,98122, Messina, Italy

Clinical case

The male patient, aged 84 years, was admitted as anemergency patient at the GeneraI Surgery ward VI at theMessina University Hospital with a diagnosis of "rightstrangulated inguinal-scrotal hernia".. .. .

The patient mentioned no anomalies m his family orphysiological history. . .

The remote pathological history was positive forurinary lithiasis, atherosclerotic cardiopat~y, and ri?htfemoral obstructive arteriopathy. He mentioned havingpreviously undergone two operations for left inguinalhernia and having suffered, for about 20 years, from. alarge right inguinal-scrotal hernia, which was easilyreduced.

About 5 days before admittance, the patient com-plained of the onset of worsening painat the site of thehernial swelling, which at the same time had becomeirreducible. He stated that he did not have fever, vom-iting, or disturbances of intestinal function.

Objective local examination showed the presence of. alarge right inguinal-scrotal swelling, roughly ovaI mshape, with a maximum diameter of about 15 cm, cov-ered by red and edematous skin, very painful on pal-pation and irreducible. The local ex~mination or theabdomen did not show other pathological elements.

Once admitted, the patient was subjected to routinelab tests and direct x-rays of the abdomen, revealing nopathological elements, and to an ecographic examina-tion of the scrotum, which was reported as: "Theswelling appears made up of a significantl~ edem.atousand thickened layer of skin; it contains herniated visceraprobably composed of hollow viscera and an inftamedomentum. There was also a fair quantity of corpuscularliquid in the area of the hernial vis~era. The .situationleads us to diagnose a hernial forrnation cornplicated bystrangulation." .

We decided to subject the patient to surgery with apreoperative diagnosis of "Suspected strangulated rightinguinal-scrotal hernia (epiploic strarigulation")".

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Hernioplasty

The skin and the subcutaneous adipose tissue wereedematous, as were the underlying muscle-aponeuroticlayers. Isolation of a large sac of an indirect inguinal-scrotal hernia, protruding through a wide opening,which affected, by dislocating downwards the lowerepigastric vessels, the entire rear wall of the inguinalcanal. On opening, the hernial sac appeared occupied byabundant quantities of purulent material and containedthe caecum, a large part of the right colon, the last ilealloop, and the omentum, significantly edematous andstuck to each other and to the inner wall cf the sac byabundant fibrinous deposits. The appendix had signifì-cantly increased in size and was subject to a gangrenousprocess, more evident in the lower visceral tract. Thepresence of fibrinous pseudomembranes at the neck ofthe sac prevented the diffusion of the inflammatoryprocess to the abdominal cavity. Taking every precau-tion to avoid the risk of peritoneal contamination duringsurgical manoeuvres, we proceeded with appendicecto-my and, after toilette with antiseptic solution, with re-duction of the herniated viscera in the abdominal cavity.Since this was a sliding inguinal hernia, with an in-complete sac, we proceeded with the partial resection ofthe sac and its subsequent closure, after having posi-tioned a Redon aspiration drain in the right iliac fossa.Considering the precarious conditions of the funiculusand testicle, affected and damaged by the acute inflarn-matory process, we decided to proceed with orchectomy.We performed a hernioplasty according to a modifiedShouldice technique, including positioning of a seconddrain in the inguinal-scrotal area and repair of the skinusing loop suture.

In the first three days after surgery, the patient re-ceived antibiotic therapy (cefalosporine), and at thefourth day, when he showed no local or generaI com-plications, after recovery of the intestinal function andremo vaI of the drains, he was discharged.

Discussion,

The presence of the vermiform appendix (withoutcomplications) in the sac of an inguinal hernia is a rareoccurrence in inguinal hernias. In literature, it isreported with an incidence of about 1% [2].

In our experience, out of 1,341 inguinal hernias op-erated on, we found it in only seven cases (0.6%), alwayson the right side and in male patients. In six cases, it wasa Iarge indirect inguinal-scrotal hernia (congenital in onecase), and in one case, a direct hernia.

Much rarer, or better, very exceptionally, is the caseof an appendix complicated by acute appendicitis in ahernial sac. In literature, its incidence varies between the0.13% reported by Ryan et al. in 1937 [3], and the 1%reported by Carey in 1967 [4], after a study carried outon all the appendix operations performed at the Mil-waukee County GeneraI Hospital in the previous

decade. We ha ve observed only one case (0.08%) in thelast 13 years.

Cases of acute appendicitis in a hernial sac have beenreported in patients of ages varying between 3 weeksand 88 years; the sex most affected by inguinal hernias isthe male, while the occurrence of acute appendicitis inthe sac of a crural hernia is more frequent in femaIesubjects [3, 4, 5, 6].

The diagnosis is always made on the operating tableseeing that, as in the case, we report, the clinical pictureis simiIar to that of a strangulated hernia; there lack,however, in the large majority of cases, clinical signs ofacute abdominal conditions, radiological indications ofstrangulation of the hollow viscera and disturbances ofthe intestinal canalisation. For this reason, a differentialdiagnosis is made with epiploic strangulation, or, in thecase of small hernias, with Richter's hernia (parietalstrangulation) [2, 5, 6, 7, 8].

In the cases reported in the literature, appendicecto-my was always performed through herniotomy and, inthe case in which there was no peritoneal contamination,at the same time as the hernial repair [3, 4, 5, 8, 9].

Only Lyass et al. report having preferred, in the casethey reported, to put off repair of the inguinal hernia,giving priority to the treatment of a retroperitoneal ab-scess secondary to the appendicular inflammation [2].Vermillion et al. in 1999 describe the laparoscopicreduction of Amyand's hernia [lO].

In none of the cases reported in the literature wasrepair, due to the presence of appendicitis, performedusing prosthesis implantation, but rather with suturingtechniques (Postempski, Bassini, Shouldice).

Orchectomy, performed in two cases reported in theliterature and in the case we observed, may becomenecessary, especially in older patients, due to elernentsof the funicuIus being affected by the appendicularinflammatory process [8, 9].

MortaIity is reported in the Iiterature with an inci-dence varying between 14 and 30% and is closely linkedto a peritoneal spread of the septic process [4, 5, 9].

Conclusions

The first consideration regards the confirmation of theexceptional nature of acute appendicitis in a hernial sac.It is the onIy case we have met with in over 1,300inguinaI hernia operations.

The onset and evoIution of the clinicaI picture areseen, then, to be of significant interest and follow that ofa hernial strangulation, with the only difference that thesymptoms do not include disturbances of the intestinalcanalisation. For this reason, the final diagnosis is madeonly on the operating tab1e.

Surgical treatment obviously involves appendicecto-my, the toilette of the abscess cavity (taking utmost careto avoid the spread of the inflammatory process to theabdominal cavity), the introduction of intraperitonealand scrotal drains and the execution of herniopIasty,

which, due to the contaminated operating fieId, is per-formed without the impIantation of prosthetic materia!.

Orchectomy, as in the case we observed, occasionaIIybecomes necessary, since the funicuIus and testicIe areinvoIved in and damaged by the inflammatory process,and couId represent a source of postoperative sepsis.

References

l. Amyand C (1736) Of an inguinal rupture, with a pin in theappendix coeci, incrusted with stone; and some observations onwounds in the guts. Phil Trans Royal Soc 39 :329

2. Lyass S, Kim A, Bauer J (1997) Perforated appendicitis withinan inguinal hernia: case report and review of the literature. AmJ Gastroenterol 92(4):700-2

3. Ryan WJ (1937) Hernia of the vermiform appendix. Ann Surg106:135

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4. Carey LC (1967) Appendicitis occuring in hernias: a report oflO cases. Surgery 61 :236

5. Ottaviani M, Maglio MN, Papa F, Zitarelli V, Alario G, DiMarzo A (1997) Acute gangrenous appendicitis in incarceratedinguinal hernia. A case report. Minerva Chir 52(6): 831-3

6. Voitk AJ, Macfarlane JK, Estrada RL (1974) Ruptured ap-pendicitis in femoral hernias: report of two cases and review ofthe literature. Ann Surg 179:24

7. Di Bartolomeo N, Lanci-Lanci C, Marchese E, Staniscia G,Craboledda P (1993) Acute Phlegmonous appendicitis due to avillous adenoma in a hernial sac. Case report. Minerva Chir48(8): 431-4

8. Serrano A, Norman B, Ackerrnan B (1979) Perforated appen-dicitis in an incarcerated inguinal hernia. Arch Surg 114:968

9. Davies MG, O'Byrne P, Stephens RB (1990) Perforated ap-pendicitis presenting as an irreducible inguinal hernia. Br J ClinPract 44(11 ):494-5

IO. Vermillion JM, Abernathy SW, Snyder SK (1999) Laparo-scopi c reduction of Amyand's hernia. Hernia 3: 159-160

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