CASE STUDY by Garrett N . Klutts , MD ; 1 Nina Bonwich , MD 1
1
University of Arkansas for Medical Sciences , Little Rock , Ark .
Amyand ’ s Hernia : A Rare Presentation of an Inguinal Hernia
Introduction
An inguinal hernia repair is a common operation performed by surgeons that accounts for more than 700,000 operations in the U . S . 1 In 0.1 % of inguinal hernia repairs , the appendix is found in the hernia sac . 2 This was first recognized by Claudius Amyand in 1735 and is known as Amyand ’ s hernia . This is a case report of the management of Amyand ’ s hernia as well as a review on the topic .
Case
A 62-year-old male presented to the general surgery clinic with a right groin bulge after a previous laparoscopic right inguinal hernia repair a decade prior . He reported a two-year history of worsening right groin bulge with discomfort on physical exertion . On physical exam , he had a reducible bulge in his right groin . Based on his clinical presentation , a recurrence of his right inguinal hernia was diagnosed . He was scheduled for an open right inguinal hernia repair . In the operating room , once dissection and isolation of the hernia sac were achieved , the sac was opened , and the cecum and the appendix were found within – consistent with Amyand ’ s hernia ( Figure 1 ). The appendix and cecum both appeared healthy , therefore no resection was performed . The hernia was repaired in Lichtenstein fashion . He had no complications .
Figure 1 .
Discussion
The clinical diagnosis of Amyand ’ s hernia is identical to an inguinal hernia , with the patient presenting with a tender inguinal bulge . Therefore , this is usually not appreciated until the patient is in the operating room . An Amyand ’ s hernia is almost exclusively found in a right-sided inguinal hernia , given the location of the appendix , and is more common in males . 3 Preoperative imaging ( CT or ultrasound ) can lead to a diagnosis of an Amyand ’ s hernia prior to an operation . 4 Management is dependent on the clinical scenario , most notably the appearance of the appendix , and guidelines have been published by Losanoff and Basson . 5 This stratifies the hernia as type one through four , with management recommendations depending on the type ( Table 1 ). 5
Conclusion
The incidence of an Amyand ’ s hernia is rare but includes two of the most common pathologies seen by a surgeon . Given the high volume of inguinal hernia repairs performed by surgeons , an Amyand ’ s hernia is likely to be encountered during one ’ s career . Having a basic understanding of the entity , along with a treatment algorithm , will help a surgeon be prepared for its management .
References
1 . Schumpelick V , Treutner KH , Arlt G . Inguinal hernia repair in adults . Lancet . 1994 Aug 6 ; 344 ( 8919 ): 375-9 . doi : 10.1016 / s0140- 6736 ( 94 ) 91404-4 . PMID : 7914310 .
2 . Adamantios Michalinos , Demetrios Moris , Spiridon Vernadakis . Amyand ’ s hernia : a review . The American Journal of Surgery , Volume 207 , Issue 6 , 2014 , Pages 989-995 , ISSN 0002-9610 , https :// doi . org / 10.1016 / j . amjsurg . 2013.07.043 .
3 . Adrián Morales-Cárdenas , César Felipe Ploneda-Valencia , Victor Hugo Sainz-Escárrega , Alvaro Cuauhtemoc Hernández-Campos , Eliseo Navarro-Muñiz , Carlos René López-Lizarraga , Carlos Alfredo Bautista-López , Amyand hernia : Case report and review of the literature , Annals of Medicine and Surgery , Volume 4 , Issue 2 , 2015 , Pages 113-115 , ISSN 2049-0801 , https :// doi . org / 10.1016 / j . amsu . 2015.03.007 .
4 . Kueper , M . A ., Kirschniak , A ., Ladurner , R . et al . Incarcerated recurrent inguinal hernia with covered and perforated appendicitis and periappendicular abscess : case report and review of the literature . Hernia 11 , 189 – 191 ( 2007 ). https :// doi . org / 10.1007 / s10029-006-0163-6
5 . Losanoff , J . E ., Basson , M . D . Amyand hernia : a classification to improve management . Hernia 12 , 325 – 326 ( 2008 ). https :// doi . org / 10.1007 / s10029-008-0331-y
Type of Hernia Features Surgical Management
TABLe 1 .
1 Normal appendix
2 Acute appendicitis localized in the sac
3 Acute appendicitis , peritonitis
4
Acute appendicitis , other abdominal pathology
Reduction or appendectomy ( depending on age ), mesh hernioplasty Appendectomy through hernia , endogenous repair Appendectomy through laparotomy , endogenous repair Appendectomy , diagnostic workup , and other procedures as appropriate
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