Amyand’s Hernia: Rare Presentation of a Common Ailment

Abstract

Inguinal hernia with vermiform appendix as content is known as Amyand's hernia. It is a rare entity but we encountered four cases within six months. A 52-year-old female had high grade fever and evidence of inflammatory pathology involving the ileocaecal region. She was initially managed conservatively and subsequently underwent exploratory laparatomy. The appendix was perforated and herniating in the inguinal canal. Appendectomy was done with herniorrhaphy without mesh placement. A 74-year-old male with bilateral inguinal hernia, of which, the right side was more symptomatic, underwent open exploration. Operative findings revealed a lipoma of the sac and a normal appearing appendix as content. Contents were reduced without appendectomy and mesh hernioplasty was performed. A 63-year-old male with an obstructed right sided hernia underwent emergency inguinal exploration which revealed edematous caecum and appendix as content without any inflammation. Contents were reduced without any resection. Herniorrhaphy was performed without mesh placement. A 66-year-old male with an uncomplicated right inguinal hernia underwent elective surgery. The sac revealed an appendix with adhesions at the neck. Contents were reduced after adhesiolysis and hernioplasty was performed with mesh placement. Emphasis is made to the rarity of disease, variation in presentation, and difference in treatment modalities depending upon the state of appendix.

Amyand’s Hernia: an Up-to-Date Review of the Literature

“…In 0.13% of all cases, the appendix is inflamed. It should be noted that appendiceal perforation leads to a dramatic increase of the mortality rate (15-30%), due to severe abdominal sepsis (2,3,6,12).…”

“…The incidence of acute appendicitis in the general population is 8%, whereas-as mentioned above -incidence of appendicitis present in an inguinal hernia is reported to be 0.1% (12,13). The exact mechanism of appendicitis, within an inguinal hernia is not fully understood (5).…”

“…(4) Inflammatory swelling of the appendix may be the beginning of a vicious cycle. Thus, Amyand's hernia becomes irreducible, accentuating the swelling due to venous stasis and causing an impaired microcirculation of the appendix wall, resulting in bacterial overgrowth and translocation (11,12).…”

“…The primary CT signs considered as pathognomonic for Amyand's hernia are a blind ending tubular structure inside the hernia sac, arising from the base of the caecum, wall thickening, hyperemia and periappendiceal fat stranding (12,20).…”

“…As a general rule, in case of a non-inflamed appendix, the patient undergoes hernia repair without appendicectomy (12,19,22,31). Researchers sharing this opinion believe that this approach could decrease postoperative complications, as a clean surgery is not converted to a clean-contaminated one.…”