Amyand's hernia complicated with appendix perforation treated by two-stage surgery consisting of laparoscopic appendectomy followed by elective inguinal hernioplasty: A case report

Emergency totally laparoscopic surgery for appendicitis in right Amyand's hernia associated to symptomatic left inguinal hernia: A case report

INTRODUCTION AND IMPORTANCE

Amyand's hernia is a rare type of inguinal hernia which contains vermiform appendix in the inguinal sac, seldom complicated by acute appendicitis. It is usually repaired by open inguinal approach, but laparoscopic technique has been increasingly described in literature; nevertheless, standard of care is far from being defined. Here we report the case of Amyand's hernia complicated by acute appendicitis and simultaneous symptomatic left inguinal hernia, both repaired by laparoscopic technique.

CASE PRESENTATION

A 85-years-old man presented with acute appendicitis in Amyand's hernia and simultaneous incarcerated left inguinal hernia.

CLINICAL DISCUSSION

After complete preoperative work-up, the patient underwent laparoscopic appendectomy and laparoscopic bilateral hernia repair with mesh.

CONCLUSION

Laparoscopic approach may be safe and feasible for Amyand's hernia treatment in emergency setting when performed by expert hands, with minimized risk of surgical site infection (SSI), quick recovery and reduced hospital stay. Laparoscopic hernia repair with mesh can be a reasonable approach in selected cases of bilateral or recurrent hernia, and concomitant intrabdominal inflammation, especially when contamination is scarse and limited to a restricted area.

Amyand's hernia in a patient with acute complicated diverticulitis. A case report and review of the literature

INTRODUCTION

Amyand's hernia with an inflamed or perforated appendix is rare with incidence of 0.1 % and 0.01 % of cases respectively. It has been described in conjunction with cecal perforation, cholecystitis and ureterolithiasis. Yet, its association with acute sigmoid diverticulitis has never been reported before.

PRESENTATION OF CASE

A 57-year-old male presented to the emergency department with acute abdomen and an indurated right inguinal mass. A preoperative computed tomography (CT) scan reported a giant inflamed sigmoid diverticulum and an Amyand's hernia with a complicated appendicitis. The patient was taken to the operating room and a midline laparotomy incision was made. A giant sigmoid diverticulum with ischemic patches was encountered. The cecal appendix was found inside the right inguinal canal, with a perforation in its distal third. A Hartmann's procedure, appendicectomy and non-mesh inguinal hernia repair was accomplished.

DISCUSSION

Case reports of Amyand's hernia in patients with simultaneous abdominal conditions are scarce. Symptoms in these patients could be various and may lead to preoperative imaging and diagnosis. In this case acute abdomen in physical examination demanded imaging analysis and a preoperative diagnosis of acute diverticulitis and Amyand's hernia with a perforated appendicitis was made.

CONCLUSIONS

Amyand's hernia with acute perforated appendicitis is a rare entity. CT scan is useful for diagnosis of Amyand's hernia and associated conditions. Preoperative diagnosis of Amyand's hernia and concomitant abdominal disease aids in the therapeutic approach and management. To our knowledge this is the first case report of an Amyand's hernia in a patient with acute diverticulitis.

Amyand's hernia complicated with appendicitis: an interval approach with transabdominal laparoscopic appendectomy and laparoscopic hernioplasty-a case report

Amyand's hernia is a rare classification of inguinal hernia where the vermiform appendix is located within the hernial sac. This case report discusses a patient presenting with abdominal and groin pain shown to be an Amyand's hernia complicated by acute appendicitis on computed tomography. The patient was treated with a two-stage approach, involving transabdominal laparoscopic appendectomy and elective laparoscopic hernioplasty after recovery. As some controversy exists regarding the timing of appendectomy and hernioplasty, we examine the benefits of the interval approach in the reduction of postoperative infection risk compared with a concurrent approach in patients presenting with Amyand's hernia complicated by appendiceal inflammation.

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.

Perforated necrotic appendix in Amyand's hernia treated with appendicectomy and simple suture repair of the inguinal hernia

A 50-year-old man was referred to the emergency department by his general practitioner with a tender right-sided irreducible inguinal hernia (previously reducible), right-sided testicular pain and scrotal swelling. Clinical examination revealed a non-reducible, tender right inguinal-scrotal hernia and swollen right scrotum. Blood tests showed raised inflammatory markers. The patient went on to have a CT scan which was reported to show an indirect right inguinal-scrotal hernia possibly containing terminal ileum and small bowel mesentery. The scan also showed increased infiltrate changes within the hernia sac suggesting incarceration with possible early strangulation but no obvious evidence of bowel obstruction. The patient was taken to the operating theatre and found to have a large right inguinal-scrotal hernia containing pus and a perforated necrotic appendix. He went to have an appendicectomy and sutured repair of the hernia. Postoperatively, the patient made a good recovery and was discharged 2 days postsurgery.

A total laparoscopic treatment strategy for Amyand's hernia complicated with appendicitis: A case report

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An appendix incarcerated in the inguinal hernia is defined as Amyand’s hernia.

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Preoperative diagnosis of Amyand’s hernia is feasible with ultrasound and CT.

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Laparoscopy for diagnostic and therapeutic purposes has been on an upward trajectory.

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A potential total laparoscopy treatment strategy for Amyand’s hernia was proposed, with fair outcomes.

Introduction

The presence of a vermiform appendix in an inguinal hernia sac is known as Amyand’s hernia. It is even rarer with complicated appendicitis. Formerly it was treated via an open groin approach; recently there are new trends involving the use of laparoscopy for reduction and management of appendix. Conversely the role of laparoscopy in the following hernia repair was less discussed, with no standard care. We reported a case of Amyand’s hernia complicated with appendix which was managed via a total laparoscopic strategy.

Presentation of case

A 49-year-old male presented with right groin mass with progressive pain for 3 days. Physical exams revealed incarcerated right inguinal hernia. Amyand's hernia with acute appendicitis was diagnosed preoperatively via computed tomography (CT). Emergent diagnostic laparoscopy was performed. Appendix was reduced, with appendectomy justified for signs of appendicitis. An interval total extraperitoneal (TEP) hernioplasty was performed 3 month later, with no adverse events postoperatively.

Discussion

In virtue of previous literature, we proposed a total laparoscopic strategy for Amyand’s hernia which consists of transabdominal diagnostic laparoscopy, management of appendix, and either immediate or elective laparoscopic hernioplasty, based on status of appendix.

Conclusion

This laparoscopic treatment strategy is feasible for Amyand’s hernia, with minimized risk of surgical site infection (SSI), fair recovery and cosmesis.