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Amyand's hernia: a rare inguinal hernia

Amyand's hernia: a rare inguinal hernia JSCR 2013; 9 (2 pages) doi:10.1093/jscr/rjt043 Case Report 1 2,* Jonathan Green and Luke G. Gutwein Division of General Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, 01655, USA and Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA *Correspondence address. Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall Suite 232, Indianapolis, IN 46202, USA. Tel: þ1-317-274-3636; E-mail: gutwein@iupui.edu Received 1 May 2013; accepted 31 May 2013 Inguinal hernia repair is commonplace in general surgery practice and an estimated 700 000 are performed each year in the USA. The presence of the vermiform appendix contained in the hernia sac, or an Amyand’s hernia, is exceedingly rare, occurring in 1% of inguinal hernia patients. We report the intra-operative findings of a standard inguinal hernia repair and discuss the management of the four types of Amyand’s hernia. INTRODUCTION incision parallel to the inguinal ligament. Subcutaneous tissue through Scarpa’s fascia was divided until aponeurotic fibers of An Amyand’s hernia is a rare occurrence where the vermiform the external oblique were visualized. After dividing the exter- appendix is found in an inguinal hernia sac. It is most com- nal oblique to the superficial inguinal ring, the contents of the monly found intra-operatively during a right-sided inguinal inguinal canal were then circumscribed using blunt dissection. hernia repair [1]. We present a case in which an Amyand’s The hernia sac lateral to the inferior epigastric pedicle was dis- hernia was discovered in a patient with both an umbilical and sected away from the spermatic cord to the deep inguinal ring. a right-sided inguinal hernia. The sac was opened illustrating the cecum and vermiform ap- pendix (Fig. 1). There were no inflammatory changes of the appendix or cecum. The sac contents were reduced into the CASE REPORT peritoneal cavity. The hernia sac was excised and the periton- eum was suture ligated. We performed a tension-free polypro- A 61-year-old African-American male was seen in the surgery pylene mesh repair. The patient was discharged the same day. clinic with a 6-year history of an umbilical and enlarging right He returned to clinic 1 month later with no complications and inguinal hernia. The umbilical hernia was symptomatic no recurrence of his hernias. causing intermittent discomfort. The right inguinal hernia was also symptomatic and had progressively enlarged over time. He denied any changes in bowel habits or history of intestinal DISCUSSION obstruction. On physical examination, his abdomen was soft, non-tender Claudius Amyand was a French born English Surgeon who in and non-distended. A small supra-umbilical tender bulge was 1735 successfully performed and recorded the repair of an in- present and incarcerated. An inguinal examination was signifi- guinal hernia in an 11-year-old patient. The patient was found cant for a right-sided, tender, reducible mass without scrotal to have the vermiform appendix in his hernia sac. Since then, involvement. the presence of the vermiform appendix in a hernia sac has On the day of surgery, the patient was prepped, and draped been deemed an ‘Amyand’s hernia’ [2]. in an aseptic technique. Initially, the umbilical hernia was The incidence of an Amyand’s Hernia is 1% of inguinal repaired primarily without complication. The right inguinal hernias occurring most often in male patients. They are most hernia repair was approached with a 5 cm right-sided oblique commonly located on the right side due to the location of the Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.# The Author 2013. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by-nc/3.0/), which permits non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com. Page 2 of 2 J. Green and L.G. Gutwein made using CT with oral contrast, in patients with suspicion of appendicitis. When scrotal involvement is suspected ultra- sound is a low cost alternative without radiation [1]. Losanoff and Basson created a classification scale to identify and treat Amyand’s hernias (Table 1)[4, 5]. A Type 1 hernia has a normal appendix in an inguinal hernia, which is managed with a reduction and mesh repair. Types 2–4 have acute appendicitis within an inguinal hernia sac. Type 2 has an inflamed nonperforated appendix. Type 3 has a perforated appendix and type 4 is complicated with intra- abdominal pathology. Type 2–4 hernias are managed with appendectomy and primary repair (without mesh). In add- ition, to the primary repair and appendectomy, type 3 includes a laparotomy for abdominal irrigation, possible Figure 1: Hernia sac (A) opened containing cecum (B) and vermiform orchiectomy or colectomy and type 4 includes investigation appendix (C); epiploic appendage (D), tenia coli (E). of pathology [4, 5]. Our patient had a Type 1 Amyand’s hernia and underwent a mesh repair without an appendectomy. In the pediatric popu- lation, however, a prophylactic appendectomy would have Table 1: Losanoff and Basson classification of Amyand’s hernia [4–6] been performed (without mesh repair), because children and adolescents have a higher risk of acquiring acute appendicitis Classification Description Surgical management [4, 5]. In summary, Amyand’s hernia is a rare occurrence, but Type 1 Normal appendix in an inguinal Hernia reduction, mesh hernia repair offer variety in their presentations and managements. Our case of a Type 1 Amyand’s hernia was repaired with mesh and Type 2 Acute appendicitis in an inguinal Appendectomy, primary hernia, without abdominal sepsis repair of hernia without did not require an appendectomy. mesh Type 3 Acute appendicitis in an inguinal Laparotomy, hernia, with abdominal wall or appendectomy, primary peritoneal sepsis repair without mesh REFERENCES Type 4 Acute appendicitis in an inguinal Manage as Type 1–3, 1. Amyand C. Of an inguinal rupture, with a pin in the appendix caeci, hernia, with abdominal pathology investigate pathology as incrusted with stone; and some observations on wounds in the guts. Philos needed Trans R Soc Lond 1736;39:329–36. 2. Burgess PL, Brockmeyer JR, Johnson EK. Amyand hernia repaired with Bio-A: a case report and review. J Sur Educ 2011;68:62–6. 3. Ballas K, Kontoulis T, Skouras C, Triantafyllou A, Symeonidis N, appendix. The appendix has also been found in obturator, um- Pavlidis T, et al. Unusual findings in inguinal hernia surgery: report of 6 bilical and incisional hernias [1]. Of inguinal hernias, only rare cases. Hippokratia 2009;13:169–71. 4. Losanoff JE, Basson MD. Amyand hernia: what lies beneath—a proposed 0.1% has an inflamed appendix [3 – 6]. This is a result of classification scheme to determine management. Am Sur 2007;73: either primary inflammation of the appendix causing edema 1288–90. of the internal inguinal ring or incarceration of a normal ap- 5. Losanoff JE, Basson MD. Amyand hernia: a classification to improve management. Hernia 2008;12:325–6. pendix by abdominal wall musculature [1]. 6. Psarras K, Miltiadis L, Baltatzis M, Pavlidis E, Tsitlakidis A, As in our patient, most Amyand’s hernia’s are discovered Symenodis N, et al.. Amyand’s hernia-a vermiform appendix presenting in intra-operatively. However, pre-operative diagnosis can be an inguinal hernia: a case series. J Med Case Rep 2011;5:463. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Amyand's hernia: a rare inguinal hernia

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Oxford University Press
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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2013.
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10.1093/jscr/rjt043
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Abstract

JSCR 2013; 9 (2 pages) doi:10.1093/jscr/rjt043 Case Report 1 2,* Jonathan Green and Luke G. Gutwein Division of General Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, 01655, USA and Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA *Correspondence address. Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall Suite 232, Indianapolis, IN 46202, USA. Tel: þ1-317-274-3636; E-mail: gutwein@iupui.edu Received 1 May 2013; accepted 31 May 2013 Inguinal hernia repair is commonplace in general surgery practice and an estimated 700 000 are performed each year in the USA. The presence of the vermiform appendix contained in the hernia sac, or an Amyand’s hernia, is exceedingly rare, occurring in 1% of inguinal hernia patients. We report the intra-operative findings of a standard inguinal hernia repair and discuss the management of the four types of Amyand’s hernia. INTRODUCTION incision parallel to the inguinal ligament. Subcutaneous tissue through Scarpa’s fascia was divided until aponeurotic fibers of An Amyand’s hernia is a rare occurrence where the vermiform the external oblique were visualized. After dividing the exter- appendix is found in an inguinal hernia sac. It is most com- nal oblique to the superficial inguinal ring, the contents of the monly found intra-operatively during a right-sided inguinal inguinal canal were then circumscribed using blunt dissection. hernia repair [1]. We present a case in which an Amyand’s The hernia sac lateral to the inferior epigastric pedicle was dis- hernia was discovered in a patient with both an umbilical and sected away from the spermatic cord to the deep inguinal ring. a right-sided inguinal hernia. The sac was opened illustrating the cecum and vermiform ap- pendix (Fig. 1). There were no inflammatory changes of the appendix or cecum. The sac contents were reduced into the CASE REPORT peritoneal cavity. The hernia sac was excised and the periton- eum was suture ligated. We performed a tension-free polypro- A 61-year-old African-American male was seen in the surgery pylene mesh repair. The patient was discharged the same day. clinic with a 6-year history of an umbilical and enlarging right He returned to clinic 1 month later with no complications and inguinal hernia. The umbilical hernia was symptomatic no recurrence of his hernias. causing intermittent discomfort. The right inguinal hernia was also symptomatic and had progressively enlarged over time. He denied any changes in bowel habits or history of intestinal DISCUSSION obstruction. On physical examination, his abdomen was soft, non-tender Claudius Amyand was a French born English Surgeon who in and non-distended. A small supra-umbilical tender bulge was 1735 successfully performed and recorded the repair of an in- present and incarcerated. An inguinal examination was signifi- guinal hernia in an 11-year-old patient. The patient was found cant for a right-sided, tender, reducible mass without scrotal to have the vermiform appendix in his hernia sac. Since then, involvement. the presence of the vermiform appendix in a hernia sac has On the day of surgery, the patient was prepped, and draped been deemed an ‘Amyand’s hernia’ [2]. in an aseptic technique. Initially, the umbilical hernia was The incidence of an Amyand’s Hernia is 1% of inguinal repaired primarily without complication. The right inguinal hernias occurring most often in male patients. They are most hernia repair was approached with a 5 cm right-sided oblique commonly located on the right side due to the location of the Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.# The Author 2013. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by-nc/3.0/), which permits non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com. Page 2 of 2 J. Green and L.G. Gutwein made using CT with oral contrast, in patients with suspicion of appendicitis. When scrotal involvement is suspected ultra- sound is a low cost alternative without radiation [1]. Losanoff and Basson created a classification scale to identify and treat Amyand’s hernias (Table 1)[4, 5]. A Type 1 hernia has a normal appendix in an inguinal hernia, which is managed with a reduction and mesh repair. Types 2–4 have acute appendicitis within an inguinal hernia sac. Type 2 has an inflamed nonperforated appendix. Type 3 has a perforated appendix and type 4 is complicated with intra- abdominal pathology. Type 2–4 hernias are managed with appendectomy and primary repair (without mesh). In add- ition, to the primary repair and appendectomy, type 3 includes a laparotomy for abdominal irrigation, possible Figure 1: Hernia sac (A) opened containing cecum (B) and vermiform orchiectomy or colectomy and type 4 includes investigation appendix (C); epiploic appendage (D), tenia coli (E). of pathology [4, 5]. Our patient had a Type 1 Amyand’s hernia and underwent a mesh repair without an appendectomy. In the pediatric popu- lation, however, a prophylactic appendectomy would have Table 1: Losanoff and Basson classification of Amyand’s hernia [4–6] been performed (without mesh repair), because children and adolescents have a higher risk of acquiring acute appendicitis Classification Description Surgical management [4, 5]. In summary, Amyand’s hernia is a rare occurrence, but Type 1 Normal appendix in an inguinal Hernia reduction, mesh hernia repair offer variety in their presentations and managements. Our case of a Type 1 Amyand’s hernia was repaired with mesh and Type 2 Acute appendicitis in an inguinal Appendectomy, primary hernia, without abdominal sepsis repair of hernia without did not require an appendectomy. mesh Type 3 Acute appendicitis in an inguinal Laparotomy, hernia, with abdominal wall or appendectomy, primary peritoneal sepsis repair without mesh REFERENCES Type 4 Acute appendicitis in an inguinal Manage as Type 1–3, 1. Amyand C. Of an inguinal rupture, with a pin in the appendix caeci, hernia, with abdominal pathology investigate pathology as incrusted with stone; and some observations on wounds in the guts. Philos needed Trans R Soc Lond 1736;39:329–36. 2. Burgess PL, Brockmeyer JR, Johnson EK. Amyand hernia repaired with Bio-A: a case report and review. J Sur Educ 2011;68:62–6. 3. Ballas K, Kontoulis T, Skouras C, Triantafyllou A, Symeonidis N, appendix. The appendix has also been found in obturator, um- Pavlidis T, et al. Unusual findings in inguinal hernia surgery: report of 6 bilical and incisional hernias [1]. Of inguinal hernias, only rare cases. Hippokratia 2009;13:169–71. 4. Losanoff JE, Basson MD. Amyand hernia: what lies beneath—a proposed 0.1% has an inflamed appendix [3 – 6]. This is a result of classification scheme to determine management. Am Sur 2007;73: either primary inflammation of the appendix causing edema 1288–90. of the internal inguinal ring or incarceration of a normal ap- 5. Losanoff JE, Basson MD. Amyand hernia: a classification to improve management. Hernia 2008;12:325–6. pendix by abdominal wall musculature [1]. 6. Psarras K, Miltiadis L, Baltatzis M, Pavlidis E, Tsitlakidis A, As in our patient, most Amyand’s hernia’s are discovered Symenodis N, et al.. Amyand’s hernia-a vermiform appendix presenting in intra-operatively. However, pre-operative diagnosis can be an inguinal hernia: a case series. J Med Case Rep 2011;5:463.

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Journal of Surgical Case Reports – Oxford University Press

Published: Sep 11, 2013

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