Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
CASE REPORT  
Year : 2012  |  Volume : 5  |  Issue : 4  |  Page : 344-346
Incarcerated recurrent Amyand's hernia


1 Department of General Surgery, National Naval Medical Center, Bethesda, MD, USA
2 Department of Surgery, Walter Reed Army Medical Center, Washington, DC, USA

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Date of Submission21-Jun-2011
Date of Acceptance07-Sep-2011
Date of Web Publication15-Oct-2012
 

   Abstract 

Amyand's hernia is a rarity and a recurrent case is extremely rare. A 71-year-old male with a previous history of right inguinal hernia repair presented to the emergency department with a 1-day history of pain in the right groin. A physical examination revealed a nonreducible right inguinal hernia. A computed tomography scan showed a 1.3-cm appendix with surrounding inflammation within a right inguinal hernia. An emergent right groin exploration revealed an incarcerated and injected non-perforated appendix and an indirect hernia. Appendectomy was performed through the groin incision, and the indirect hernia defect was repaired with a biological mesh (Flex-HD). We hereby present this unique case - the first reported case of recurrent Amyand's hernia and a literature review of this anatomical curiosity.

Keywords: Amyand′s hernia, incarcerated, recurrent

How to cite this article:
Quartey B, Ugochukwu O, Kuehn R, Ospina K. Incarcerated recurrent Amyand's hernia. J Emerg Trauma Shock 2012;5:344-6

How to cite this URL:
Quartey B, Ugochukwu O, Kuehn R, Ospina K. Incarcerated recurrent Amyand's hernia. J Emerg Trauma Shock [serial online] 2012 [cited 2020 Nov 29];5:344-6. Available from: https://www.onlinejets.org/text.asp?2012/5/4/344/102407



   Introduction Top


Amyand's hernia is an inguinal hernia containing vermiform appendix. The diagnosis was accredited to Claudius Amyand, who was the first person to describe the condition in 1735. [1] The entity is rare with a reported incidence of 0.5-1% for those associated with normal appendix. [2] The incidence of acute appendicitis in the inguinal canal is about 0.1%. [3] We hereby present, to the best of our knowledge, the first case of recurrent nonperforated Amyand's hernia repaired with a biological mesh.


   Case Report Top


A 71-year-old male patient presented to the emergency department with an acute onset of a right groin pain of 24-hour duration. He denied any bowel symptoms. His surgical history includes a plug and patch (ULTRAPRO hernia system) repair of a symptomatic right inguinal hernia 17 months earlier and a sigmoid resection for complicated diverticulitis 20 years earlier. A physical examination revealed a nontoxic appearing male with an exquisitely tender, nonreducible, small right inguinal hernia. His laboratory results revealed a leukocyte count of 9.2 × 10 3 /mm 3 (normal (4.3-10.8) × 10 3 /mm 3 ). A right incarcerated recurrent inguinal hernia was suspected, and this was confirmed by a computed tomography scan [Figure 1]. The patient was therefore taken to the operating room emergently for right groin exploration. At exploration, a chronically incarcerated, inflamed appendix within the indirect hernia sac [Figure 2] was identified. Appendectomy was performed through the groin incision, and the indirect hernia was repaired with a biological mesh (Flex-HD) due to the contaminated field [Figure 3]. The postoperative period was uneventful, and the patient was discharged home 2 days after the surgery. At 5-month follow-up, the patient is free from recurrence.
Figure 1: CT scan of abdomen/pelvics showing incarcerated Amyand's hernia (arrow indicates inflammed appendix within the hernia sac)

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Figure 2: Appendix within the indirect hernia sac

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Figure 3: Final repair with a biological mesh

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   Discussion Top


Amyand's hernia was credited to Claudius Amyand after he performed the first reported successful appendectomy in an 11-year-old boy in 1735. [4] The patient presented with an enterocutaneous fistula due to the perforation of the appendix by a pin within an inguinal hernia sac. The procedure lasted half an hour and involved an open appendectomy with the primary repair of the hernia defect. Ironically, the first appendectomy in the United States occurred in 1887 and was also a case of appendicitis in an inguinal hernia. [5] Amyand's hernia is therefore an inguinal hernia containing vermiform appendix. The appendix can also be found in a femoral hernia, which is known as De Garengeot hernia. [6] The reported incidence of a normal appendix within the inguinal hernia is approximately 1%; [2] however, the presence of appendicitis in the inguinal hernia is only 0.l%. [3] Amyand's hernia is more common in men and is often right-sided. [7] Left-sided Amyand had been described, [7],[8],[9] and it is often associated with situs inversus, mobile cecum, and malrotation of the intestines. [7],[8],[9] Most patients present with a nonreducible and tender inguinal hernia. [3],[10] Preoperative diagnosis is difficult, but imaging with computed tomography (CT) scan can suggest the diagnosis, [11] as was in our case. Most Amyand's hernias are therefore diagnosed intraoperatively. [10]

Management is surgical and it is based on intraoperative findings according to Losanoff: type 1 - normal appendix; type 2- inflamed appendix; type 3 - inflamed appendix with abdominal sepsis or perforated appendix; type 4- inflamed appendix and other unrelated abdominal pathology. [12] The management of Losanoff type 2-4 requires appendectomy followed by primary hernia repair. [3],[12] The use of a prosthetic mesh to repair Amyand's hernia with Losanoff type 2-4 findings has been reported. [13] The management of Losanoff type 1 requires hernia repair with or without appendectomy, and this is very controversial. Proponents for routine appendectomy believe that the removal of the appendix at the first operation will decrease the risks of appendicitis and future surgery. However, antagonists to this practice argues that leaving the appendix in situ will allow for the use of a prosthetic mesh for the hernia repair and future use of the appendix as a conduit for urinary diversion when the need arises.

In the present case, routine appendectomy was deferred in the first operation because of the intraoperative finding of Losanoff type 1 Amyand. At recurrence, the appendix was incarcerated, inflamed, and injected, and this prompted immediate appendectomy. The hernia was repaired with a biological mesh due to the contaminated field. We used Flex-HD for the repair, and this is an acellular hydrated dermal matrix derived from human allograft skin developed by Ethicon through alliance with Musculoskeletal Transplant Foundation (http://www.ethicon360.com/products/flex-hd-acelular-hydrated-dermis-family). Similar to other biological meshes, this allograft serves as a scaffold to support cellular repopulation and vascularization. [14]


   Conclusion Top


Amyand's hernia is a rare entity with diverse presentation, preoperative diagnostic dilemma, and requirement of knowledge of two surgical problems: symptomatic hernia and appendicitis. Management is surgical and includes hernioplasty with or without appendectomy depending on the intraoperative findings, and routine prophylactic appendectomy is not indicated. The biological mesh plays a role in the management of Losanoff type 2-4 Amyand's hernia. Our unique case of recurrent incarcerated Amyand's hernia elaborates the above findings.

DOD Disclaimer

The views expressed in this case report are those of the authors and do not reflect the official policy of the Department of the Navy (DON), Department of Army (DOA), Department of Defense (DOD), or US Government.

 
   References Top

1.Hutchinson R. Amyand's hernia. J R Soc Med 1993;86:104-5.  Back to cited text no. 1
[PUBMED]    
2.Anagnostopoulou S, Dimitroulis D, Troupis TG, Allamani M, Paraschos A, Mazarakis A. Amyand's hernia: A case report. World J Gastroenterol 2006;12:4761-3.  Back to cited text no. 2
    
3.D'Alia C, Lo Schiavo MG, Tonante A, Taranto F, Gagliano E, Bonanno L, et al. Amyand's hernia: Case report and review of literature. Hernia 2003;7:89-91.  Back to cited text no. 3
[PUBMED]    
4.Amyand C. Of an inguinal rupture, with a pin in the appendix caeci, incrusted with stone, and some observations of wound in the guts. Phil Trans Royal Soc 1973;39:329-36.  Back to cited text no. 4
    
5.Creese PG. The first appendectomy. Surg Gynecol Obstet 1953;97:643-52.  Back to cited text no. 5
[PUBMED]    
6.Powell HD. Gangrenous appendix in femoral hernial sac. Lancet 1954;267:1211-2.  Back to cited text no. 6
[PUBMED]    
7.Sharma H, Gupta A, Shekhawat NS, Memon B, Memon MA. Amyand's hernia: A report of 18 consecutive patients over the 15-year period. Hernia 2007;11:31-5.  Back to cited text no. 7
[PUBMED]    
8.Breitenstein S, Eisenbach C, Wille G, Decurtins M. Incarcerated vermiform appendix in a left-sided inguinal hernia. Hernia 2005;9:100-2.  Back to cited text no. 8
[PUBMED]    
9.Malik KA. Left sided Amyand's hernia. J Coll Physicians Surg Pak 2010;7:480-1.  Back to cited text no. 9
    
10.Inan I, Myers PO, Hagen ME, Gonzalez M, Morel P. Amyand's hernia: 10 years' experience. Surgeon 2009;7:198-202.  Back to cited text no. 10
[PUBMED]    
11.Luchs JS, Halpern D, Katz DS. Amyand's hernia: Prospective CT diagnosis. J Comput Assist Tomogr 2000;24:884-6.  Back to cited text no. 11
[PUBMED]    
12.Losanoff JE, Basson MD. Amyand hernia: What lies beneath - a proposed classification scheme to determine management. Am Surg 2007;73:1288-90.  Back to cited text no. 12
[PUBMED]    
13.Torino G, Campisi C, Testa A, Baldassarre E, Valenti G. Prosthetic repair of a perforated Amyand's hernia: Hazardous or feasible? Hernia 2007;11:551-2.  Back to cited text no. 13
[PUBMED]    
14.Menon NG, Rodriguez ED, Byrnes CK, Girotto JA, Goldberg NH, Silverman RP. Revascularization of human acellular dermis in full-thickness abdominal wall reconstruction in the rabbit model. Ann Plast Surg 2003;50:523-7.  Back to cited text no. 14
[PUBMED]    

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Correspondence Address:
Benjamin Quartey
Department of General Surgery, National Naval Medical Center, Bethesda, MD
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.102407

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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