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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 44-46

A rare cause of left lower quadrant pain: Amyand's hernia


1 Department of General Surgery, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey
2 Department of Emergency Medicine, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey

Date of Web Publication11-Mar-2019

Correspondence Address:
Faruk Pehlivanli
Department of General Surgery, Faculty of Medicine, Kirikkale University, 71850 Kirikkale
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_83_18

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  Abstract 


Amyand's hernia is defined as the presence of a normal or inflamed appendix vermiformis within the inguinal hernia sac and was first described by Claudius Amyand. Most cases of Amyand's hernia are seen on the right side associated with the normal anatomy of the appendix. Diagnosis is usually made during hernia surgery. In this study, a rare case is reported of a patient operated on for left-side incarcerated inguinal hernia and determined with acute appendicitis within the hernia sac.

Keywords: Appendix, Amyand's hernia, left Amyand's hernia


How to cite this article:
Pehlivanli F, Aydin O, Karaca G, Eroglu O, Misirligil S, Figen C. A rare cause of left lower quadrant pain: Amyand's hernia. Apollo Med 2019;16:44-6

How to cite this URL:
Pehlivanli F, Aydin O, Karaca G, Eroglu O, Misirligil S, Figen C. A rare cause of left lower quadrant pain: Amyand's hernia. Apollo Med [serial online] 2019 [cited 2019 Jul 16];16:44-6. Available from: http://www.apollomedicine.org/text.asp?2019/16/1/44/253875




  Introduction Top


Amyand's hernia is defined as the presence of a normal or inflamed appendix vermiformis within the inguinal hernia sac.[1] It was first described by Claudius Amyand in 1735, with the sighting of perforated appendix tissue within a right-side inguinal hernia sac of an 11-year-old child.[1],[2] In addition to appendix tissue, the inguinal sac may also contain umbilical, obturator, and incisional hernias.[3],[4],[5] While normal appendix tissue is found in the inguinal hernia sac at the rate of 1%, the development of appendicitis is a more uncommon table at the rate of 0.1%.[1],[6] The preoperative diagnosis of these cases is very difficult and can be confused with incarceration or strangulation hernia.[5] We will present of a patient operated on for left-side incarcerated inguinal hernia and determined with acute appendicitis within the hernia sac.


  Case Report Top


A 66-year-old male presented with complaints of nausea and vomiting and abdominal pain that had increased in the last 3 h and with a swelling approximately 7 cm × 10 cm in size that had been present in the left groin for 2 years. In the physical examination, a nonreduced inguinal hernia was observed in the left inguinal region [Figure 1]. The patient had no history of operations, a diagnosis of chronic obstructive pulmonary disease, and apart from rhonchi heard in the lungs, other system examination results were normal. In the laboratory examinations, the biochemical parameters were normal and in the full blood count, white blood cell was 9300/mm3. No findings of obstruction were observed on the abdominal plain radiograph. With a diagnosis of irreducible hernia, a general surgery specialist was consulted, and as the hernia could not be reduced by the surgeons, the patient was admitted for surgery. A left inguinal incision was made for exploration, and the hernia sac descending to the scrotum was opened. Within the hernia sac, it was observed that a section of the sac wall was formed of the appendix vermiformis, cecum, omentum, and small intestine [Figure 2]. Appendectomy was applied to the patient, and the inguinal hernia sac was repaired using prolene mesh with the Lichtenstein method. The patient was discharged from hospital on the 4th day postoperatively, and in the subsequent 6-month period of follow-up, no complicatons were observed.
Figure 1: Incarcerated left inguinoscrotal hernia in the physical examination

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Figure 2: Appendix vermiformis, cecum, omentum, and small intestine within the sac forming part of the wall of the hernia sac

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  Discussion Top


Amyand's hernia is seen on the left side very rarely, and the vast majority of reported cases have been with a right-side location, consistent with the normal anatomy of the appendix on the right side. In conditions such as mobile cecum, intestinal malrotations, situs inversus, and overly long appendix, Amyand's hernia may be seen on the left side.[6],[7],[8] In the current case, as only mobile cecum was determined, it is an example of rarely observed left-side Amyand's hernia.

Although the normal structure of the appendix can be protected by the hernia, as a result of increased abdominal pressure or adhesions, the appendix adheres to the mesentery leading to impaired bleeding of the appendix and may cause acute appendicitis.[3],[9] It is extremely difficult to diagnose Amyand's hernia preoperatively. If computed tomography or ultrasonography is used to show the presence of the appendix within the hernia sac, a definitive diagnosis is made during the operation.[10],[11],[12] In the current case, diagnosis was made during the operation.

Treatment options for Amyand's hernia vary according to the status of the appendix within the hernia sac. Ofili stated that it was necessary to perform appendectomy in all cases of Amyand's hernia, whereas Losanoff et al. reported that if the appendix was normal, appendectomy could be made to young patients only, and the appendix vermiformis should be reduced without appendectomy in all other cases.[13],[14] Johari et al. recommended appendectomy to eliminate problems of the diagnosis in left-side hernias, regardless of the status of the appendix.[15]

Another controversy in the treatment of Amyand's hernia is the use of mesh. Carey reported that the use of mesh following appendectomy in Amyand's hernia increased the development of fistula and wound site infection associated with the inflammatory response and contamination.[3] Priego et al. applied appendectomy to six cases of incarcerated inguinal hernia containing appendix vermiformis and mesh was used in three cases. In five of the six cases, no problems were observed, but in one of the cases where mesh was used, infection developed in the surgical wound site.[16] Gurer et al. retrospectively scanned a series of 1950 cases operated on for inguinal hernia, and acute appendicitis or appendix vermiformis within the hernia sac was determined in 12 cases. These hernias all had right-side location. Appendectomy was applied to 11 cases and reduction to 1, as this was a 5-month-old patient with an indirect hernia without incarceration, strangulation, or inflammation of the vermiform appendix.[17] In the current case, as there was adhesion of appendix tissue within the left incarcerated inguinoscrotal hernia, appendectomy was applied, and as the operating area was seen to be clean, repair was made with mesh. During the 6-month follow-up period, no local or systemic problems were determined.


  Conclusion Top


Incarcerated inguinal hernias which require emergency intervention may be confused with Amyand's hernia. Therefore, physicians must have good knowledge of diagnosis and treatment management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Michalinos A, Moris D, Vernadakis S. Amyand's hernia: A review. Am J Surg 2014;207:989-95.  Back to cited text no. 1
    
2.
Hutchinson R. Amyand's hernia. J R Soc Med 1993;86:104-5.  Back to cited text no. 2
    
3.
Carey LC. Acute appendicitis occurring in hernias: A report of 10 cases. Surgery 1967;61:236-8.  Back to cited text no. 3
    
4.
Doig CM. Appendicitis in umbilical hernial sac. Br Med J 1970;2:113-4.  Back to cited text no. 4
    
5.
Archampong EQ. Strangulated obturator hernia with acute gangrenous appendicitis. Br Med J 1969;1:230.  Back to cited text no. 5
    
6.
Ghafouri A, Anbara T, Foroutankia R. A rare case report of appendix and cecum in the sac of left inguinal hernia (left Amyand's hernia). Med J Islam Repub Iran 2012;26:94-5.  Back to cited text no. 6
    
7.
Mewa Kinoo S, Aboobakar MR, Singh B. Amyand's hernia: A Serendipitous diagnosis. Case Rep Surg 2013;2013:125095.  Back to cited text no. 7
    
8.
Al Maksoud AM, Ahmed AS. Left Amyand's hernia: An unexpected finding during inguinal hernia surgery. Int J Surg Case Rep 2015;14:7-9.  Back to cited text no. 8
    
9.
Bendavid R. The unified theory of hernia formation. Hernia 2004;8:171-6.  Back to cited text no. 9
    
10.
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. 10
    
11.
D'Alia C, Lo Schiavo MG, Tonante A, Taranto F, Gagliano E, Bonanno L, et al. Amyand's hernia: Case report and review of the literature. Hernia 2003;7:89-91.  Back to cited text no. 11
    
12.
Weber RV, Hunt ZC, Kral JG. Amyand's hernia: Etiologic and therapeutic implications of two complications. Surg Rounds 1999;22:552-6.  Back to cited text no. 12
    
13.
Ofili OP. Simultaneous appendectomy and inguinal herniorrhaphy could be beneficial. Ethiop Med J 1991;29:37-8.  Back to cited text no. 13
    
14.
Losanoff JE, Basson MD. Amyand hernia: A classification to improve management. Hernia 2008;12:325-6.  Back to cited text no. 14
    
15.
Johari HG, Paydar S, Davani SZ, Eskandari S, Johari MG. Left-sided amyand hernia. Ann Saudi Med 2009;29:321-2.  Back to cited text no. 15
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16.
Priego P, Lobo E, Moreno I, Sánchez-Picot S, Gil Olarte MA, Alonso N, et al. Acute appendicitis in an incarcerated crural hernia: Analysis of our experience. Rev Esp Enferm Dig 2005;97:707-15.  Back to cited text no. 16
    
17.
Gurer A, Ozdogan M, Ozlem N, Yildirim A, Kulacoglu H, Aydin R, et al. Uncommon content in groin hernia sac. Hernia 2006;10:152-5.  Back to cited text no. 17
    


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