An approach to the management of Amyand’s hernia and presentation of an interesting case report

Management of Perforated Appendicitis in Amyand's Hernia: A Multidisciplinary Approach to Complex Postoperative Complications

Amyand's hernia is an exceptionally rare condition in which the appendix is located within an inguinal hernia sac. While it is typically asymptomatic, the occurrence of appendicitis or perforation within these hernias presents significant diagnostic and therapeutic challenges. We report a unique case involving a 31-year-old male patient who developed perforated appendicitis within an Amyand's hernia, resulting in severe intra-abdominal infection and complex postoperative complications, including the formation of multiple abscesses at three different sites. A multidisciplinary approach, involving general surgery, infectious disease, interventional radiology (IR), and urology, was crucial for effective source control and infection management. This case underscores the importance of individualized surgical decision-making in cases of Amyand's hernia with significant inflammatory involvement, emphasizing the necessity for timely recognition and intervention to minimize complications and improve patient outcomes.

Strangulated Amyand's hernia with testicular necrosis in an adult: A case report

INTRODUCTION

Amyand's hernia is a rare condition defined by the presence of the vermiform appendix within an inguinal hernia sac. The occurrence of Amyand's hernia with testicular necrosis is particularly uncommon, further complicating its clinical presentation and management.

CASE PRESENTATION

A 50-year-old male presented with a two-year history of progressive right scrotal swelling, acutely worsened over four days with pain and fever. Examination revealed a firm, tender, irreducible right scrotal mass with overlying erythema. Laboratory tests showed leukocytosis. Imaging confirmed an inflamed appendix within the hernial sac, consistent with Amyand's hernia complicated by abscess formation. Emergency surgery revealed a gangrenous appendix, scrotal abscess, and necrotic right testicular tissue. The patient underwent appendectomy, orchiectomy, hernia repair, and abscess drainage. He recovered uneventfully, with symptom resolution and no recurrence at follow-up.

DISCUSSION

The progression of Amyand's hernia to appendicitis and subsequent perforation, as seen in our case, can result in severe complications, including abscess formation and testicular necrosis. The Losanoff and Basson classification categorizes Amyand's hernia based on the appendix's condition and associated complications, ranging from a normal appendix (Type 1) to severe extra-sac pathology such as gangrene or malignancy (Type 4). Our case aligns with Type 4, involving a perforated appendix with gangrene and a scrotal abscess, necessitating extensive surgical intervention.

CONCLUSION

This case highlights the rarity and complexity of Amyand's hernia in adults, emphasizing the need for prompt recognition and tailored management to achieve favorable outcomes.

Amyand's Hernia: Incarcerated Appendicitis in a Recurrent Inguinal Hernia in an Adult

Inguinal hernias are among the most common cases presented to a surgeon. In spite of extensive research and clinical experience over centuries, inguinal hernias still pose anatomical challenges for operating surgeons, especially with a propensity for recurrence. One such complicated entity is the Amyand's hernia - defined as an inguinal hernia contained within the hernial sac - the vermiform appendix - as the herniated content. It is a rare clinical presentation and carries with it certain complexities with regard to operative decisions and clinical management. We present a case of a 71-year-old male presenting with a recurrent inguinal hernia, with an incarcerated, inflamed appendix as the content; managed surgically with appendicectomy and herniorraphy, without the use of a prosthetic mesh.

Controversies Regarding Mesh Utilisation and the Attitude towards the Appendix in Amyand's Hernia-A Systematic Review

Inguinal hernia containing the vermiform appendix is a rare entity. It is more common in children than in adults. It can be discovered incidentally during the surgical intervention performed for the cure of the inguinal hernia or when the appendix shows inflammatory changes, a situation that can lead to diagnostic confusion with a number of other diseases. Imaging can guide the diagnosis, which often comes as an intraoperative surprise. The therapeutic approach is controversial both in terms of whether or not to perform an appendectomy in the case of an appendix without inflammatory changes and especially in terms of using a mesh during the hernia repair process. Since the pathology is not very frequent, there are no standardized stages in terms of surgical ethics that can guarantee good surgical practice. The study aimed to carry out a review of the specialized literature to obtain some conclusions or trends regarding the management of this pathology. The low frequency of this type of hernia did not allow the consultation of large-scale studies or extensive reviews focusing on case reports or case series communications. The obtained results were statistically analyzed and integrated in relation to the surgical attitude depending on the particularities of the condition.

Appendiceal Carcinoid Tumor Contained in a Large Inguinal Hernia: A Case Report

We report the first case of a clinically diagnosed incidental appendiceal carcinoid tumor contained in an incarcerated inguinal hernia without inflammation of the appendix. A 67-year-old white man underwent elective open repair of an incarcerated right inguinal hernia containing small bowel, cecum, appendix, and ascending colon. He was found to have a grossly abnormal mass at the tip of his appendix. Appendectomy was performed, and histopathologic analysis confirmed the presence and adequate resection of a neuroendocrine tumor. It is important for general surgeons to be aware that unusual presentations of appendiceal tumors may not be associated with appendiceal inflammation or related symptoms.

Amyand's hernia: presumptive diagnosis by CT and literature review

Amyand's hernia is a rare inguinal hernia containing the appendix presenting mainly in male adults. The clinical presentation is usually without symptoms, however an inflammation can occur leading to strangulation, necrosis or rupture of the appendix. Differential diagnosis may be difficult including orchitis, testicular torsion, inflammation of the ovaries and bowel inflammation.

We present a case of a 61 years old, male patient who was presented with persistent right abdominal pain. There was no medical history of previous hospitalization or surgery of the abdomen. Laboratory tests and radiological investigation with plain radiographs and ultrasound were not clear. A CT scan with contrast imaging was performed to reveal the diagnosis.

Amyand's hernia is difficult to be revealed and a high index of suspicion is needed in order to promptly diagnose the hernia and proceed to the appropriate treatment. CT scan is critical contributing to the accurate depiction and to the classification of the hernia.

Implications of the presence of the vermiform appendix inside an inguinal hernia (Amyand's hernia): a systematic review of the literature

PURPOSE

To identify and sum all available evidence pertaining to the management of Amyand's hernia (AH).

METHODS

A systematic search of the MedLine, Scopus, and Google Scholar databases was performed for studies published until January 2020.

RESULTS

In total, 111 studies incorporating 161 patients were identified, 96 (86.4%) being case reports, 11 (9.9%) case series, and 4 (3.7%) retrospective patient cohorts. Mean patient age was 58.5 ± 19.6 years with 136 (83.9%) being males and 25 (16.1%) females. Furthermore, 149 (92.5%) cases were right-sided hernias while 12 (7.5%) cases were left-sided. Overall, 62.3% of patients presented emergently and 77.3% of patients' cohort were eventually diagnosed with incarcerated AH. Preoperative diagnosis of AH was established in 23.1% of patients and was achieved either by ultrasound (25%) or CT scan (75%). Operative findings consisted of normal appendix in 73 (45.4%) cases, uncomplicated appendicitis in 62 (38.5%) patients, and perforated appendix in 26 (16.1%). Regarding patients with appendicitis, mesh placement was reported for 17 (21.2%), herniorrhaphy was performed for 51 (63.7%) while 12 (15.1%) patients did not undergo hernia repair during the initial operation. Mesh utilization rates were significantly higher in patients with a normal appendix. Seven cases involved AH containing appendiceal neoplasms. Thirteen cases (8.6%) of postoperative complications were documented and a single case of postoperative death.

CONCLUSION

AH is a rare type of inguinal hernia usually complicated by appendicitis. Hernia reconstruction should be tailored to each patient individually according to the extent of inguinal canal inflammation.

Simultaneous laparoscopic total extraperitoneal inguinal hernia repair and laparoscopic appendectomy for Amyand's hernia: a case report

Background

An Amyand’s hernia is defined by the presence of a vermiform appendix within an inguinal hernia sac. Most of these cases are not diagnosed preoperatively and the surgical approach is dependent on the type present and associated intraoperative findings. We present a case of a preoperatively diagnosed Amyand’s hernia in a man who underwent treatment by simultaneous laparoscopic totally extraperitoneal repair and laparoscopic appendectomy.

Case presentation

We encountered the case of a 76-year-old Japanese man with a right inguinal pain. Ultrasound and computed tomography confirmed his vermiform appendix herniated into the right inguinal canal. We managed a simultaneous laparoscopic total extraperitoneal inguinal hernia repair with mesh and laparoscopic appendectomy. He was discharged without any postoperative morbidity.

Conclusions

We recommend laparoscopic appendectomy and totally extraperitoneal hernia repair with mesh after laparoscopic reduction for Amyand’s hernia.

Amyand's hernia with acute gangrenous appendicitis and cecal perforation: A case report and review of the literature

INTRODUCTION

An Amyand's hernia is a heterogeneous clinical condition defined by the presence of the vermiform appendix within an inguinal hernia sac, which may or may not contain other abdominal contents or pathologic inflammatory changes. Herein we present an exceptionally rare case of an Amyand's hernia containing acute appendicitis and a perforated cecum.

PRESENTATION OF CASE

A 46-year-old male with a right inguinal hernia of 2-3 year duration presented to our Emergency Department complaining of acute onset abdominal and groin pain. The patient was diagnosed with an incarcerated right inguinal hernia and underwent emergent surgical repair. Intraoperatively a reactive fluid was found within the hernia sac that prompted an exploratory laparotomy for suspected bowel perforation. The hernia was then found to contain an inflamed gangrenous appendix with an inflamed and perforated cecum. An ileocecectomy and enteroenterostomy was performed and the hernia defect was repaired without mesh.

DISCUSSION

With an estimated incidence of only 1%, Amyand's hernias are rare and lack a clear evidence-based management scheme. Moreover, they can contain a diverse range of pathologic features and presentations that can complicate diagnosis and treatment. To avoid potential morbidity and mortality, the surgeon must consider an Amyand's hernia on his or her differential when operating on inguinal hernias and be aware of the associated presentations, complications, and management schemes.

CONCLUSION

There is a paucity of reports describing simultaneous appendicitis and cecal perforation within an Amyand's hernia. In our case, ileocecectomy and Bassini hernia repair with close follow-up led to a favorable outcome.

Mesh Inguinal Hernia Repair and Appendectomy in the Treatment of Amyand's Hernia with Non-Inflamed Appendices

Amyand's hernia is defined as protrusion of the vermiform appendix in an inguinal hernia sac. It is a rare entity with variable clinical presentation from normal vermiform appendix to abscess formation due to perforation of acute appendicitis. Although surgical treatment includes appendectomy and hernia repair, appendectomy in the absence of an inflamed appendix and use of a mesh in cases of appendectomy remain to be controversial. The aim of this study was to review the experience of mesh inguinal hernia repair plus appendectomy performed for Amyand's hernia with noninflamed appendices. There were five male patients with a mean age of 42.4 ± 16.1 years in this retrospective study in which Amyand's hernia was treated with mesh inguinal hernia repair plus appendectomy for noninflamed appendices. Patients with acute appendicitis and perforated vermiform appendix were excluded. There were four right sided and one bilateral inguinal hernia. Postoperative courses were uneventful. During the follow-up period (14.0 ± 7.7 months), there was no inguinal hernia recurrence. Mesh inguinal hernia repair with appendectomy can be performed for Amyand's hernia in the absence of acute appendicitis. However, presence of fibrous connections between the vermiform appendix and the surrounding hernia sac may be regarded as a parameter to perform appendectomy.

Amyand's Hernia: A Case Report

Amyand's hernia is a rare and atypical hernia characterized by the herniation of the appendix into the inguinal sac. This hernia may be present without symptoms until inflammation of the appendix may lead to incarceration, strangulation, necrosis, perforation or rupture. Early symptoms include tenderness and inguinal swelling which may be misdiagnosed as a strangulated hernia. This condition can be difficult to diagnose clinically. Ultrasound and Computed Tomography may aid in diagnosis. This article presents a rare case of Amyand's hernia followed by a discussion of the epidemiology, diagnosis, imaging details and treatment options for this condition.

A complicated case of amyand's hernia involving a perforated appendix and its management using minimally invasive laparoscopic surgery: A case report

INTRODUCTION

Amyand's hernia is a rare condition of inguinal hernia in which the appendix is incarcerated within the hernia sac through the internal ring. Complications include acute appendicitis and perforated appendicitis, which are rare in incidence, accounting for about 0.1% of cases.¹ These complications prove a diagnostic challenge due to their vague clinical presentation and atypical laboratory and radiological findings. Until recently, open appendectomy was the mainstay of treatment. Laparoscopic surgery offers a less invasive approach to confirming a diagnosis and serving as a therapeutic tool in equivocal cases.

CASE PRESENTATION

We report a case of a previously healthy 20-year-old male presenting with atypical signs and symptoms, as well as blood investigation results, and radiological findings of a perforated appendix within an Amyand's hernia. The patient was successfully managed using a minimally invasive laparoscopic appendectomy approach.

DISCUSSION

Until recently, open appendectomy was considered the mainstay in the management of complicated Amyand's hernia. Laparoscopic surgery provides a new avenue for dealing with diagnostic uncertainty with advantages including faster recovery time, reduced hospital stay, and better quality of life.

CONCLUSION

This case report highlights the concealing effects of an Amyand's hernia on a perforated appendix, the considerations required when an equivocal diagnosis present and the safe use of the minimally invasive laparoscopic surgery in the treatment of this rare condition.

Amyand's hernia: a case series with critics of role of appendectomy

Amyand's hernia is an inguinal hernia that contains vermiform appendix in its sac. It consists 1% of all inguinal hernias while appendicitis in an Amyand's hernia accounts for 0.1% of all appendicitis cases. Its clinical image is identical to that of an incarcerated or perforated inguinal hernia. Diagnosis is usually established intraoperatively. Hernioplasty (with or without mesh repair and with or without appendectomy) is the treatment of choice. According to Losannof and Basson's criteria, performance of appendectomy shall depend on vermiform appendix's inflammation status. In this case series, authors present three patients who had to undergo prophylactic appendectomy because of medical conditions, unrelated to appendix's inflammation status thus escaping from therapeutic frame set by Losanoff and Basson's criteria.

Neuroendocrine tumor of the appendix inside an incarcerated Amyand's hernia

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Neuroendocrine tumor of the appendix inside an incarcerated Amyand’s hernia is extremely rare.

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The diagnosis of Neuroendocrine tumor in a such emergency situation is a real challenge.

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Treatment of the hernia defect in a such condition is interesting.

Amyand’s hernia is a rare type of hernia where the vermiform appendix is within an inguinal hernia sac. Tumors of the appendix are quite uncommon. The coincidence of an Amyand’s hernia with neuroendocrine tumor of the appendix, as in our case, is even more rarely reported.

We report the case of an 81-year-old male who presented with an incarcerated right inguinal hernia. After resuscitation, the clinical diagnosis was confirmed by computed tomography. It showed an incarcerated right inguinal hernia which contained the distal ileum, cecum, thickened appendix, as well as a small amount of fluid. Subsequently, the patient was prepared for emergency surgery. During the operation, the hernia sac was found and opened. The appendix was swollen. Therefore, appendectomy was performed. The inguinal defect was repaired using the Modified Bassini Technique. The patient had an uneventful postoperative recovery and surprisingly the histopathology of the appendix revealed a 1.5 cm well-differentiated low grade neuroendocrine tumor (carcinoid) of the appendix tip.

An incidental finding of neuroendocrine tumor of the appendix in a patient with s hernia is extremely rare. A high index of suspicion is the key to diagnose such a coincidence in order to safely and optimally treat such a condition.

Incarcerated Amyand hernia with simultaneous rupture of an adenocarcinoma in an inguinal hernia sac: a case report

INTRODUCTION

An Amyand's hernia is a rare occurrence of an inguinal hernia, with an estimated prevalence of 1%. The major complications of an Amyand's hernia include necrotizing fasciitis of the anterior abdominal wall and secondary intestinal perforation. Though the incidence of this type of hernia is low, the appendix may easily become initially incarcerated, possibly leading to strangulation and perforation.

CASE PRESENTATION

A 92-year-old female patient presented to our emergency department with clinical signs of an incarcerated right inguinal hernia, accompanied by fever. A clinical examination revealed localized abdominal pain, reflecting to the right side of her groin. Laboratory tests showed leukocytosis (13,200/μL), while an abdominal X-ray showed colon distension with evidence of intestinal obstruction. Ultrasonography was performed and confirmed the presence of an inflamed tubular structure inside her right inguinal canal. Our patient underwent emergency surgery. We started with a right inguinal incision, which revealed an incarcerated right inguinal hernia, containing her ruptured appendix and showing macroscopic evidence of malignancy. A specimen biopsy was immediately performed and the results showed a ruptured cecal adenocarcinoma. The incision was slightly extended upwards, and a right hemicolectomy performed.

CONCLUSIONS

Diagnosis of an Amyand's hernia occurs primarily as an incidental finding during surgery and the optimal therapeutic approach must be considered individually for each case. Owing to the rarity of Amyand's hernia and the wide variance of its clinical characteristics, every case provides useful information toward the treatment of this type of hernia.

Amyand's hernia: a review

BACKGROUND

The presence of a vermiform appendix in an inguinal hernia sac is known as Amyand's hernia. The aim of this systematic review was to gather information concerning its prevalence, clinical image, diagnosis, and treatment.

DATA SOURCES

The MEDLINE database was thoroughly searched using the keyword "Amyand's hernia." Additional articles were gathered and evaluated.

CONCLUSIONS

The true prevalence of Amyand's hernia seems lower than classically described. Its usual clinical image is identical to that of an incarcerated hernia, and thus it is almost impossible to diagnose preoperatively, although ultrasound and computed tomography can help. Treatment includes hernioplasty with or without appendectomy and/or mesh repair depending on the vermiform appendix's inflammation status, the patient's general condition, and other factors. Amyand's hernia generally has a good prognosis, although serious complications have been described. Surgeons should be prepared if they encounter Amyand's hernia because appropriate treatment ensures hernia repair without complications and with avoidance of recurrence.

Amyand's hernia with a periappendicular abscess

We present a rare case of a perforated vermiform appendix presenting as a strangulated inguinal hernia. An 89-year-old man presented to the surgical assessment unit with a 1-week history of progressively worsening abdominal pain, fever and a tender mass in the right iliac fossa. A diagnosis of strangulated inguinal hernia was made. Intraoperatively, a perforated appendix and a pus-filled sac were found. An appendicectomy and a Bassini repair of the hernia were performed with a satisfactory postoperative outcome. In the majority of cases Amyand's hernia is an intraoperative finding and its management depends on the extent of appediceal disease. In cases of perforated appendix with periappendiceal abscess within the hernial sac, an appedicectomy with Bassini's repair is recommended.

"Uncommon Contents of Inguinal Hernial Sac": A Surgical Dilemma

Inguinal hernia repair is the most common surgery done by both young and experienced surgeons. The hernia in the inguinal region usually contains the omentum and small intestine but rarely can contain unusual contents like the appendix, ovary with fallopian tubes, urinary bladder, sigmoid colon, and cecum. The aim of this study is to present our experience of uncommon contents in the inguinal hernia sac and their surgical management. A retrospective study of 330 patients who underwent inguinal hernia repair was carried out over a period of 3 years from January 2008 to December 2011. Only five patients presented with unusual contents in the inguinal hernia sac; an incidence of 1.5 %. Two of them had vermiform appendix, with acute appendicitis (Amyand's hernia) noted in one of them. The patient with acute appendicitis underwent appendicectomy with herniorrhaphy, while in the other, hernioplasty with mesh was done as the patient was with normal appendix. In one case, the urinary bladder was the content of the inguinal hernia sac and there were two cases with the ovary and fallopian tubes as its content. In all these cases, contents were replaced back and hernia repair was done. Unusual contents of the hernial sac may create a surgical dilemma (whether to save or sacrifice the organ) during hernia repair even to an experienced surgeon.

Laparoscopic appendectomy for Amyand's hernia: a modern approach to a historic diagnosis

OBJECTIVES

This study seeks to discuss the management and diagnosis of Amyand's hernia, an exceedingly rare diagnosis.

METHODS

The case of a 60-year-old female found to have inguinal appendicitis on preoperative computed tomography imaging is presented.

RESULTS

The patient underwent concomitant laparoscopic inguinal hernia repair and appendectomy.

DISCUSSION

Laparoscopic management of Amyand's hernia should be strongly considered for repair and resection.