Amyand's hernia: a review

Amyand's hernia: a case report

An Amyand's hernia is a type of inguinal hernia where the appendix protrudes into the hernial sac. Pre-operative diagnosis is clinically challenging and ultimately the diagnosis is made intra-operatively. We report on a 75-year-old lady who presented with abdominal pain and a lump in her right groin region. She proceeded to theatre and had a diagnostic laparoscopy where she was diagnosed with an Amyand's hernia. The appendix was mildly inflamed and there was an ischemic appearance of the mesoappendix. According to the guidelines proposed by Losanoff and Basson she subsequently underwent a successful laparoscopic appendicectomy and primary repair of the hernia.

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.

Uncomplicated Amyand's hernia in a setting of abdominal wall insufficiency: a case report

INTRODUCTION

Amyand's hernia, an uncommon condition characterized by the presence of the appendix within an inguinal hernial sac (< 1% incidence), poses diagnostic and therapeutic challenges. Often it is an intraoperative finding, with almost no clinical symptoms.

CASE PRESENTATION

This is a case of an Indian male in his early 80 years, diagnosed with bilateral direct inguinal hernias, one of which contained a noninflamed appendix. Given the thinned out abdominal wall, dense adhesions, and no demarcation between layers, the decision to proceed with a modified Bassini's with Lichtenstein mesh repair without appendectomy, guided by intraoperative findings and the Losanoff-Basson Classification, reflecting the complex interplay between individual patient factors and intraoperative considerations. The patient did well during his postoperative stay and was in good health on a 45 day follow-up, with no complaints suggestive of recurrence or obstruction.

CONCLUSION

This case underscores the importance of tailored management strategies and highlights, especially in cases where recurrence and postoperative wall integrity are in question, the ongoing need for research to refine treatment guidelines for Amyand's hernia, especially in cases of appendicitis not diagnosed preoperatively.

Amyand's hernia and associated acute appendicitis: A case report

INTRODUCTION

Amyand's hernia is incarceration of vermiform appendix within inguinal hernia. Amyand's hernia associated with acute appendicitis is rare.

CASE PRESENTATION

A male in his 5th decade of life presented with enlarged right reducible inguinal scrotal swelling and each episode of incarceration relieved manually. Background history of a movement disorder. Ultrasound reported right inguinoscrotal hernia with bowel content but no obstruction seen with plain abdominal x-ray. Elective right open inguinoscrotal repair was done. Intraoperative findings included enlarged superficial ring, enlarged hyperemic appendix in indirect hernia sac adhering to caecum. After appendectomy, the sac was transfixed above caecum. Hernioplasty was done with a polypropylene, poliglecaprone 25, macroporous and partially absorbable mesh. Immediate post-operative period was uneventful. Last review at 7 months showed no complication.

CLINICAL DISCUSSION

About 1 % of inguinal hernias retain part or whole appendix. In Amyand's hernia, 0.07-0.13 % of appendix is more prone to trauma, impaired vascular supply, inflammation, and microbial multiplication. Index patient's appendix was inflamed and histology confirmed focal acute transmural inflammation and denudation of appendiceal epithelial walls. Mesh repair is generally contraindicated in appendicitis or ruptured appendix but no post-operative complication occurred in index patient up to 7 months after appendectomy via the hernia with mesh repair.

CONCLUSION

Amyand's hernia with acute appendicitis is rare. Though use of mesh during surgery is controversial, hernioplasty was done in index patient because of the predisposing history of a movement disorder and recurrence rate of herniorrhaphy.

Management of a Patient With an Obstructed Inguinal Hernia With Amyand's Variety: A Report of a Rare Case With a Review of the Literature

Amyand's hernia is a rare form of inguinal hernia, where the appendix is located within the inguinal sac. A 66-year-old male presented with an obstructed, incarcerated right inguinal hernia. He underwent an emergency herniotomy under spinal anesthesia. Intraoperatively, the hernia sac contained a viable small bowel and part of the appendix. As the appendix appeared mildly inflamed, an appendicectomy was performed, and a synthetic mesh repair was done. He received a postoperative course of antibiotics and was discharged home on day 3 after an uneventful recovery. Histology of the appendix revealed a fecolith in the absence of acute inflammation. He did not have any procedure-related complications on follow-up. Preoperative diagnosis of Amyand's hernia is a challenge due to nonspecific symptoms and rarity. Lasanoff and Basson classify Amyand's hernia and provide surgical guidance for its management. Our case belonged to the type 2 category. Management of Amyand's hernia needs an individually tailored approach rather than strict adherence to conventional guidelines. The presence of an appendicular fecolith in the absence of inflammation provides an interesting area to explore in an Amyand's hernia.

Intraoperative diagnosis of Amyand's hernia, a case report

INTRODUCTION

Hernia forms when an organ or its fascia protrudes through the continuing cavity's wall. Amyand's hernia describes an inguinal hernia containing an appendix, regardless of inflammation.

PRESENTATION OF CASE

Our patient was complaining of an increasing lump in the inguinal area. It started 5 years ago as a small mass that gradually increased, manifesting distressing symptoms. The initial diagnosis was an indirect right inguinal hernia. During the surgery, the presence of an indirect inguinal hernia was observed, and the appendix was revealed within the sac, with the observation of adhesion of the appendix tip to the sac.

DISCUSSION

Amyand's hernia describes an inguinal hernia, containing the appendix inside it. It is classified according to Losanoff and Basson depending on the presence and spread of inflammation. The diagnosis of Amyand's hernia is often made during the surgery because of its rarity and unspecific symptoms. When symptoms and signs occur, they masquerade as strangulated hernia rather than appendicitis.

CONCLUSION

Even Amyand's hernia is a rare condition; it should be a differential diagnosis in patients who come with strangulated hernia or appendicitis. More studies are needed to understand the physiology of this type of hernia. In addition, more cases should be reported to help establish guidelines for diagnosing and treating this hernia.

Unilateral Concurrent Amyand's Hernia and Inguinal Bladder Hernia (IBH): A Case Report

An inguinal hernia is a common surgical condition where abdominal contents protrude through a weakened area of the abdominal wall. While most are straightforward, rare variants can lead to significant complications. Named after the surgeon who successfully removed a vermiform appendix from a hernia sac, Amyand's hernia is a rare finding. Similarly, an inguinal bladder hernia (IBH) is a rare condition where part of the urinary bladder protrudes into the inguinal canal. We present a unique case of a 62-year-old male who presented to the emergency department with a one-day history of lower abdominal pain, exacerbated by physical exertion. The absence of associated symptoms like nausea, vomiting, fever, or urinary symptoms made his condition challenging to diagnose clinically. However, computed tomography (CT) scans of the abdomen and pelvis confirmed the diagnosis of concurrent Amyand's hernia and IBH. The definitive treatment for symptomatic and painful inguinal hernias involves surgery, either open or laparoscopic hernia repair, while asymptomatic, lower-risk inguinal hernias may be observed before intervention is warranted. This report underscores the challenge of balancing the benefits of standardizing diagnostic protocols, particularly preoperative diagnosis and management guidelines for rare variants of inguinal hernias, with the associated costs. In this case, the absence of typical urinary symptoms commonly seen in IBH further complicated the diagnostic process, exemplifying the challenge of identifying such rare anomalies. While standardized screening could help prevent serious and potentially fatal complications, it also poses a strain on medical resources and may lead to unnecessary emotional and physical stress for patients when screening for rare variants of inguinal hernias.

Amyand's Hernia: A Snap From the Learned Mind

Amyand's hernia is a rare clinical condition containing appendix as the content of hernia. The incidence of this type of hernia is rare; the appendix may become incarcerated within the sac and can lead to strangulation or perforation. This case report highlights the clinical presentation, diagnosis, and management of an Amyand's hernia in a strangulated masquerade in a 75-year-old male. It signifies the importance of early recognition and prompt surgical intervention to counteract potential complications associated with this condition.

Amyand's Hernia diagnosed preoperatively via a CT scan: A case report

Amyand's hernia is a rare type of inguinal hernia characterized by the presence of the vermiform appendix within the hernia sac. It was named after Claudius Amyand who performed the world's first successful appendectomy on an 11-year-old boy with a right inguinal hernia in 1735 and discovered a herniated appendix during surgery. This condition warrants urgent surgical treatment, with the type of surgical intervention depending on the appendix's condition. However, the nonspecific clinical presentation often complicates the preoperative diagnosis, emphasizing the critical role of imaging in surgical planning. Herein, we present the case of a 74-year-old male who presented with fever, inguinal swelling, and discomfort. Clinical suspicion of inguinal and scrotal inflammation prompted us to perform a prompt CT scan. This radiological evaluation led to a preoperative diagnosis of a Type 3 Amyand's hernia. This case highlights the significance of CT scans in the accurate and timely diagnosis of Amyand's hernia. Distinguishing between various types of Amyand's hernia is pivotal as it profoundly influences surgical decision-making and postoperative outcomes. By sharing this case, we contribute to current knowledge about Amyand's hernia, increase clinical awareness of the condition, and emphasize the crucial role of imaging in its management.

Amyand's hernia: a case of right inguinoscrotal hernia with appendiceal content

Introduction

Amyand's hernia, a rare condition where the appendix becomes lodged in the inguinal canal, poses diagnostic challenges due to its varied clinical presentations and lack of distinctive radiological features. This case underscores the importance of early detection and comprehensive diagnostic evaluation.

Case Presentation

A 30-year-old male presented with a 2-year history of right inguinoscrotal swelling, culminating in agonizing symptoms and irreducible masses over the inguinoscrotal area. Despite the absence of significant medical history, diagnostic imaging confirmed a complete right inguinoscrotal hernia and bilateral hydrocele with internal echoes.

Clinical Discussion

The case illustrates the difficulties in preoperative diagnosis of Amyand's hernia, emphasizing the reliance on imaging modalities and clinical assessment. Successful surgical intervention involving appendectomy and hernioplasty highlights the necessity for prompt diagnosis and management.

Conclusion

This case exemplifies the challenges and complexities associated with Amyand's hernia, emphasizing the importance of early recognition and comprehensive surgical planning. Moving forward, increased clinical vigilance and awareness are essential to ensure optimal patient outcomes in cases of inguinoscrotal pathology.

Amyand's Hernia: An Uncommon Encounter of an Appendiceal Presence in an Inguinal Hernia

Amyand's hernia is a rare variant of inguinal hernia characterized by the presence of the vermiform appendix within the hernia sac. It represents a unique diagnostic and management challenge for surgeons due to its low incidence and varied clinical presentations. Here, we present a case of a 45-year-old man with a one-year history of right inguinoscrotal swelling, diagnosed as a right indirect inguinal hernia. Preoperative imaging revealed the presence of omentum within the hernia sac. Intraoperatively, both the omentum and the vermiform appendix were found within the sac without evidence of inflammation. The patient underwent successful Lichtenstein meshplasty without appendicectomy. This case highlights the importance of considering Amyand's hernia in the differential diagnosis of inguinal hernias and the significance of intraoperative findings in guiding surgical management. Further studies and case reports are needed to enhance our understanding of this rare clinical entity and optimize patient outcomes.

Amyand's hernia repair in an asymptomatic patient-a case report and a review of the literature

Amyand's hernia is a rare condition, in which the appendix is found in the inguinal hernia sac. Many patients remain asymptomatic and this pathological condition is most commonly diagnosed intraoperatively. We report a case of a 66-year-old male who was admitted to the hospital for an inguinal hernia repair and the presence of the appendix in the inguinal hernia sac was discovered intraoperatively. We performed a reduction of the appendix in the abdominal cavity and a hernia repair with a mesh and a plug. There are few studies in literature about the appropriate method of treatment and, because of that, the therapeutic approach remains controversial. Therefore, we also conducted a review of the literature in order to obtain some conclusions regarding the management of Amyand's hernia.

Amyand's hernia in a 3-month-old infant: A case report

Amyand's hernia is a rare condition characterized by an inguinal hernia containing the appendix, which can lead to complications. It is more common in children and it can be challenging to diagnose due to its location, often being mistaken for other conditions like strangulated hernias, orchitis-epididymitis, or testicular torsion. Imaging, including computed tomography and sonography, plays an important role in diagnosis, which is usually made intraoperatively. A case concerning a 3-month-old boy with a large acute scrotum that had been evolving for 4 days was presented. Clinical examination revealed a hard inguinal mass and a large scrotum with signs of inflammation. An inguinoscrotal ultrasound found a herniated appendix, suggesting the diagnosis of Amyand's hernia, which was confirmed after surgery.

Conventional herniorrhaphy followed by laparoscopic appendectomy for a variant of Amyand's hernia: a case report

BACKGROUND

Amyand's hernia (AH) is an appendix (with or without acute inflammation) trapped within an inguinal hernia. Most AH with acute appendicitis had a preexisting appendix within the hernia sac. We herein report a variant of AH that has never been described before. An inflamed appendix that was managed conservatively was found to have migrated and trapped in the sac of a previously unrecognized right inguinal hernia 6 weeks after the index admission, resulting in a secondary Amyand's hernia.

CASE PRESENTATION

A 25-year-old healthy Taiwanese woman had persistent right lower abdominal pain for 1 week and was diagnosed with perforated appendicitis with a localized abscess by abdominal computed tomography (CT). No inguinal hernia was noted at that time. Although the inflamed appendix along with the abscess was deeply surrounded by bowel loops so that percutaneous drainage was not feasible, it was treated successfully with antibiotics. However, she was rehospitalized 6 weeks later for having a painful right inguinal bulging mass for a week. Abdominal CT revealed an inflamed appendix with abscess formation in an indirect inguinal hernia raising the question of a Amyand's hernia with a perforated appendicitis. Via a typical inguinal herniorrhaphy incision, surgical exploration confirmed the diagnosis, and it was managed by opening the hernial sac to drain the abscess and reducing the appendix into the peritoneal cavity, followed by conventional tissue-based herniorrhaphy and a laparoscopic appendectomy. She was then discharged uneventfully and remained well for 11 months.

CONCLUSIONS

Unlike the traditional definition of Amyand's hernia, where the appendix is initially in the hernia sac, the current case demonstrated that Amyand's hernia could be a type of delayed presentation following initial medical treatment of acute appendicitis. However, it can still be managed successfully by a conventional tissue-based herniorrhaphy followed by laparoscopic appendectomy.

Amyand's hernia presented with strangulated and perforated appendicitis: A case report

INTRODUCTION

Amyand's hernia (AH) is a rare condition in which the vermiform appendix is incarcerated within the inguinal hernia (IH) sac. Although infrequent, it may become inflamed or perforated and can typically be diagnosed either intraoperatively or through radiographic findings.

PRESENTATION OF CASE

A 77-year-old male presented to the emergency room with constipation, fever, and an irreducible right inguinal bulge accompanied by slight localized discomfort that had persisted for ten days. Clinical examination was unremarkable, while ultrasound revealed a non-ischemic small bowel loop and a right testicular hydrocele, leading to a primary diagnosis of incarcerated IH. The patient was subsequently admitted for surgery, during which AH was confirmed. The appendix was inflamed, enlarged, and perforated, with localized abscess and internal inguinal ring stenosis. Subsequently, the surgical treatment involved appendectomy and hernia repair.

DISCUSSION

According to the appendix condition, four subtypes of AH can be encountered, with type III -perforated appendicitis- being the focus of this report. In this case report, inguinal ring stenosis was the underlying cause of complications besides the unusual presentation features that were also attributed to adhesions that prevented peritoneal involvement.

CONCLUSION

Surgeons should consider AH in the differential diagnosis of inguinal swelling and be familiar with the surgical management approach in the incidental event of AH during surgery.

Perforated Amyand hernia with an adenocarcinoma tumour presenting as a groin abscess

An Amyand hernia is an incarcerated inguinal hernia containing the appendix with or without appendicitis. This is a rare form of inguinal hernia, making up approximately 0.4%-1% of all cases. As with any hernia, this may become strangulated at any time, leading to the loss of blood supply and further development of gangrene and complications. Clinically, this can present in a manner indistinguishable from other types of inguinal hernias. In addition, the appendix can be affected by its own set of pathological processes, such as infection, inflammation, and malignancy. Not uncommonly both hernial and appendiceal complications coexist. The clinical diagnosis of an Amyand hernia remains challenging due to its low incidence and indistinct clinical presentation. At present, surgery is usually diagnostic and therapeutic. However, there is a growing number of recent reports showing the invaluable role of imaging on the diagnosis of Amyand hernias and associated complications. The correct and timely recognition of their imaging features including complications can optimize and expedite patient care by guiding diagnosis, treatment, and prognosis. Here, we report for the first time the radiological and pathological findings of a patient with a unique complicated Amyand hernia, which posed a diagnostic challenge for the clinical and radiological teams.

Amyand's Hernia: A Rare Case Study of Perforated Appendicitis in an Inguinal Hernia

Amyand's hernia is defined as the presence of an appendix contained within an inguinal hernia. An inguinal hernia is the protrusion of a small or large bowel through a peritoneal defect of the groin. In rare cases, the appendix can become incarcerated or strangulated within the hernia, cutting off the blood supply to the organ. If incarcerated, the appendix is at risk for strangulation, which can lead to rupture and cause worsening of symptoms and/or collapse. We report a case of a 76-year-old male with a history of inguinal hernia repair 30 years prior, who presented with 30 days of intermittent right lower quadrant pain and unintentional weight loss. He required emergent treatment and management. This case underscores the challenge of diagnosing concurrent inguinal hernia and appendicitis and places an emphasis on timely intervention. Treatment options vary based on the appendix's apparent condition within the hernia sac. Despite the complications, including additional drainage site and enterocutaneous fistula, the patient was discharged in stable condition. This case contributes insights into managing complex inguinal pathologies, particularly in the geriatric population.

Amyand's Hernia With Sliding Component: A Case Report

Amyand's hernia (AH) occurs when the appendix becomes part of an inguinal hernia. Amyand's hernias are typically discovered incidentally during surgery due to their variable clinical manifestations and features, such as caecum and appendix forming the sliding component in the present case. Claudius Amyand operated it for the first time in 1735. Due to the simple presentations that these patients typically exhibit, the diagnosis is extremely challenging. The choice between surgical modalities is influenced by the numerous, logically accepted advantages and disadvantages of management modalities, which are subject to debate. That being said, we believe that, in the absence of sepsis or inflammation, open repair using mesh - as long as a clean operating room and competent surgical skill are available - should be the gold standard approach.

A pictorial review of scrotal and penile pathology on computed tomography

Computed tomography (CT) may show a variety of scrotal and penile pathologic finding, but is usually not used as a first-line imaging due to its limited soft tissue contrast. Nonetheless, there are three main scenarios for imaging of the scrotum and penis with CT. Pathologies may be found incidentally in patients undergoing abdominal and pelvic CT scanning for different reasons. In emergency settings, CT is frequently performed, and the recognition of scrotal and penile pathologies by the reporting radiologist is crucial to ensure optimal patient treatment and outcome. If MRI scanning cannot be performed due to contraindications or is unavailable in resource, limited CT may be used for the further characterization of scrotal and penile pathology found on ultrasound. This pictorial review wants to familiarize general and emergency radiologists with the anatomy and possible pathological findings of the scrotum and penis on CT.

A Unique Case of Perforated Appendicitis in a Giant Incarcerated Right-Sided Inguinal Hernia: Challenges and Surgical Management

BACKGROUND Amyand hernia is a rare condition described as the presence of the appendix within an inguinal hernia. The clinical presentation of can be atypical, depending on the length of the defect's history and the size of the hernia. As inguinal hernia repair is considered a routine surgical procedure, giant hernias are mostly encountered in countries with limited medical care or with patient rejection of surgical management. CASE REPORT We report a case of a 56-year-old patient with a history of a chronic giant inguinal-scrotal hernia for more than 10 years who presented himself to the Emergency Department with acute pain in the scrotum and fever. Computed tomography revealed a perforated appendicitis located in the inferior part of the scrotum. The patient underwent a surgical procedure with an inguinal and middle laparotomy approach, revealing a full incarceration of the right and traverse colon, terminal ileal loop, and omentum, along with evidence of a perforated appendicitis. Standard appendectomy and direct hernia repair were successfully performed. CONCLUSIONS To the best of our knowledge, this is the first case of a perforated appendicitis within a right giant inguinal hernia described in the modern English-language literature. Rare in our daily practice, giant hernias are a real challenge regarding their surgical management during and after surgery, making this case with a perforated appendicitis even more arduous.

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.

Amyand's hernia with a perforated appendix and an enterocutaneous fistula: A case report

INTRODUCTION

Amyand's hernia is a rare finding accounting for less than 1 % of inguinal hernias. The appendix with its pathology within the hernia sac may become isolated from the gastrointestinal tract, which can cause further confusion in clinical diagnosis. Awareness of the possibility of such appendiceal isolation could aid in clinical diagnosis. We report a rare case of Amyand's hernia complicated with a perforated appendix and an enterocutaneous fistula.

PRESENTATION OF CASE

A 64-year-old gentleman with diabetes mellitus type II and hypertension presented with a right inguinal swelling associated with a malodorous discharge without features of intestinal obstruction. Ultrasonography revealed a right inguinal hernia with features of partial strangulation. He underwent a right inguinal exploration with subsequent debridement, appendicectomy and a herniorraphy. The patient had complete recovery and histopathology revealed acute appendicitis.

DISCUSSION

Amyand's hernia is rare and difficult to diagnose pre-operatively. Appendicitis in Amyand's hernia is rarer still and may be caused by intraluminal or extraluminal obstruction. Clinical presentation is variable and ultrasonography and computed tomography (CT) scan aid in diagnosis. Appendicectomy is regarded as unnecessary when the appendix is normal. Synthetic mesh should be avoided when the appendix is inflamed or perforated.

CONCLUSION

Amyand's hernia is rare and difficult to diagnose. Ultrasonography and CT scan are valuable tools for pre-operative diagnosis. Isolation of the appendix with its pathology within the hernia sac can add to the confusion in clinical diagnosis. Management of Amyand's hernia should be tailored according to the pathology encountered and treatment should not be delayed.

Challenges in strategies for Amyand hernia in children: literature review with clinical illustrations

Introduction

Amyand hernia (AH) is a rare disease, so there are no standard strategies and there are many different aspects at each stage of its management. Based on our own experience, we encountered these differences even in a small number of cases and therefore sought to review the literature to highlight the diversity of approaches to this pathology. This review of the literature was not intended to describe the statistical findings found in the clinical case series, but rather to highlight the clinical and surgical difficulties of AH in children. Nevertheless, we conducted an introductory statistical study based on data from PubMed and Google Scholar to understand the global prevalence of AH.

Materials and methods

The search for the key terms Amyand hernia, Amyand’s hernia, and “children” between 2003 and 2023 resulted in 52 PubMed and 548 Google Scholar articles.

Results

After the exclusion of irrelevant studies, 101 articles were found. A total of 83 case reports describing 182 pediatric patients were used to understand the demographic distribution of this pathology. Given the impossibility of further comprehensive statistical analysis (due to heterogeneous data), a narrative design was used to describe the remaining aspects of AH management. Finally, three clinical cases demonstrated the mentioned aspects.

Discussion

As a result of the search, conclusions were drawn about the main difficulties in the management of AH in children, which were discussed.

Amyand hernia as a rare cause of abdominal pain: A case report and literature review

Key Clinical Message

Amyand's hernia is an uncommon kind of inguinal hernia in which the appendix becomes entrapped within the hernia sac. In patients with an inflamed or perforated appendix, mesh repair is not recommended for hernia repair.

Abstract

Amyand's hernia is an uncommon kind of inguinal hernia in which the appendix becomes entrapped within the hernia sac. We report a 48-year-old man with a right groin protrusion and abdominal pain. In the abdominopelvic ultrasound, an appendix with a diameter of 9 mm was reported in the right inguinal canal. The patient was diagnosed with Amyand hernia.

Rosai-Dorfman Disease in a Pediatric Patient: Imaging Findings and Pathology with a brief review of the Literature

Rosai-Dorfman Disease, otherwise known as sinus histiocytosis with massive lymphadenopathy, is a rare form of non-Langerhans cell histiocytosis with an estimated incidence of 100 cases per year in the United States. Due to its variable presentation and nonspecific clinical findings, it is particularly difficult to diagnose in pediatric patients. We report a case of an 11-month-old male who presented with a 4-day history of a right groin mass. Ultrasound of the groin and pelvis demonstrated, and MRI of the abdomen and pelvis confirmed an inguinal mass with surrounding lymphadenopathy. Pathology confirmed Rosai-Dorfman Disease and the patient improved after starting oral steroid therapy. To the best of our knowledge, this is the first case of Rosai-Dorfman Disease involving the inguinal region in an infant under 1 year of age reported in the literature. In this case report, we discuss the imaging and histology findings as well as provide a brief literature review for this diagnosis.

A Radiological Review of the Unusual Contents of Inguinal Region

Background  The inguinal region is an area of complex anatomy that could contain diverse uncommon contents in routine clinical practice. Although inguinal hernia repair is one of the commonest surgeries done routinely, thorough preoperative imaging has a significant impact on the outcome of the surgery, by revealing the presence of unusual contents in the inguinal region. Aim  The aim of this article is to review the differential diagnosis of the uncommon inguinal pathologies, which can simulate an inguinal hernia, to determine, and to simplify the treatment approach. Conclusions  A profound understanding of the imaging characteristics of uncommon inguinal pathologies is crucial for both the radiologists (to prevent misdiagnosis) and the treating physicians (to avoid surgical complications) and ensure optimal management.

A Rare Case of Amyand's Hernia

A hernia is an abnormal protrusion of an organ or tissue from its containing cavity. The most common type of abdominal hernia is an inguinal hernia. When a hernia is non-reducible, it is termed an incarcerated hernia. We present one such rare case of an incarcerated appendix within a right inguinal hernia, also called Amyand's hernia (AH). We discuss current approaches toward surgically repairing this type of complicated hernia and a complication that can arise if it is not repaired in a timely manner.

Fishbone-Induced Appendicular Perforation: A Rare Case Report of Amyand's Hernia

Amyand's hernia is a rare type of hernia where the appendix is found to be the content of the inguinal hernial sac. It is most often diagnosed intraoperatively wherein the appendix may be found healthy, incarcerated, inflamed, or perforated. Claudius Amyand performed a successful appendectomy on a patient with an appendix noted in the inguinal canal and this condition was hence named after him. The incidence of Amyand's hernia is rare in inguinal hernia patients. There are no defined guidelines for the management of Amyand's hernia but adequate resuscitation followed by immediate appendectomy is widely followed. Here is a case report of a 60-year-old male presenting to the Emergency Department with an irreducible right-side inguinal hernia with features of small bowel obstruction. On exploration, Amyand's hernia was identified with appendicular tip perforation due to an impacted fishbone with pyoperitoneum. Appendectomy was done through midline laparotomy with impacted fishbone removal from the hernial sac with tissue repair of the hernia. There are as such no reported cases of fishbone-induced appendicular perforation in an Amyand's hernia in the available literature. After the exploration, we found the management of the case challenging regarding the closure of the hernia.

Appendiceal Abscess Within a Giant Amyand’s Hernia: A Case Report

Amyand's hernia is a rare clinical entity, defined as an inguinal hernia containing the appendix. Giant inguinoscrotal hernia is also a rare clinical finding that presents major operative dilemmas due to the loss of abdominal domain. Here, we report a case of a 57-year-old male who presented with a giant irreducible right inguinoscrotal hernia and obstructive symptoms. The patient underwent an emergency open right inguinal hernia repair, where an Amyand's hernia was identified. The hernia contained an inflamed appendix and associated abscess, caecum, terminal ileum, and descending colon. Using the giant sac to isolate the contamination, an appendicectomy was performed, the hernial contents reduced and the hernia repair reinforced with partially absorbable mesh. The patient recovered post-operatively and was discharged home with no recurrence on four-week follow-up. This case provides learning points on decision-making and surgical management of a giant inguinoscrotal hernia containing an appendiceal abscess, also known as Amyand's.

Appendix Playing Hide and Seek: A Variation to Amyand’s Hernia

Amyand's hernia is a rare condition where the appendix becomes trapped in the inguinal hernia sac, leading to severe complications if left untreated. Treatment typically involves surgical repair of the hernia, with the removal of the appendix if necessary. This case report presents a 65-year-old male with compromised cardiac status and a right inguinal hernia, confirmed by ultrasound. The surgery was performed under local anesthesia, and the appendix was normal and reduced back. The patient was discharged on the next day of surgery after an uneventful course in the hospital. There is a difference of opinion regarding the need for an appendectomy in an Amyand's hernia with a normal appendix, with the appendix dancing in and out of the inguinal canal while coughing on the table. The decision to remove or leave a normal appendix in this situation should be based on several factors, including the patient's age, appendix anatomy, and extent of intraoperative inflammation. In conclusion, local anesthesia can be a safe and effective option for patients who are not fit for general or spinal anesthesia. The decision to remove or leave a normal appendix in Amyand's hernia should be based on several factors.

Incarcerated Amyand Hernia Associated With Acute Appendicitis and Incidental Finding of Serrated Adenoma

BACKGROUND

Amyand hernias are rare as they represent 0.5% of all hernias. An Amyand hernia that is discovered due to acute appendicitis is even rarer, accounting for approximately 0.11% of cases. Furthermore, appendiceal neoplasms are infrequently encountered in only 0.7-1.7% of appendectomy specimens.

PURPOSE

This paper presents the case of an 85 year-old man presenting with acute appendicitis located within an amyand hernia as well as a serrated adenoma noted on final pathology.

CONCLUSIONS

An Amyand hernia is a rare diagnosis. We proceeded with laparoscopic appendectomy and interval inguinal hernia repair. Pathology should be reviewed for all patients and proper follow up ensured for all incidental findings.

Amyand's Hernia: A Radiological Solution of a Surgical Dilemma

Amyand's hernia is a rare condition whereby the appendix lies within the sac of an inguinal hernia; rarer still, the appendix can become inflamed (acute appendicitis) and is frequently misdiagnosed as a strangulated inguinal hernia. We report a case of Amyand's hernia complicated with acute appendicitis. In this case an accurate preoperative diagnosis was provided by a preoperative Computerised Tomography (CT) scan, permitting planning of treatment by a laparoscopic approach.

A rare presentation of appendicitis contained within an incisional hernia post loop ileostomy reversal - A case report

INTRODUCTION AND IMPORTANCE

Appendicitis within an incisional hernia is rare, with current literature describing a small number of cases, occurring through a variety of surgical incisions. We describe a case of appendicitis contained within an incisional hernia following reversal of a loop ileostomy, on a background of previous sigmoid cancer resection. This is the second such case we were able to identify on literature review.

CASE PRESENTATION

A 45 year old man presented with one day of migratory abdominal pain, predominantly focused at a tender, irreducible lump in his right lower quadrant, underlying the scar from previous reversal of loop ileostomy. CT on admission revealed an incisional hernia, containing an inflamed appendiceal tip. He underwent an uncomplicated laparoscopic appendicectomy and primary suture closure of the hernia defect, and was discharged the following day. Acute appendicitis was confirmed on histopathology.

DISCUSSION

Placement of a defunctioning ileostomy is common in the management of colonic cancers, and incisional hernias are a common complication. It is however rare for an appendix to be contained within a hernia sac, and even rarer for appendicitis to develop in this setting. As a result, the presentation of this condition may mimic that of an incarcerated or strangulated incisional hernia, with pre-operative diagnosis typically relying on diagnostic imaging.

CONCLUSION

Incisional hernia appendicitis is rare and presents a diagnostic challenge. Early recognition of this dual pathology is necessary to allow for prompt surgical management of both the appendicitis and hernia, as well as guiding the approach for hernia repair.

Management of appendicitis in a De Garengeot hernia: Lockwood approach

A De Garengeot hernia is a femoral hernia containing the vermiform appendix. This extremely rare hernia is associated with appendicitis and the risk of perforation and abscess formation. Given limited data, it poses both diagnostic and management difficulties. While management is generally surgical, questions remain about the best operative approach, indications for appendicectomy and optimum hernia repair technique. We describe a case of acute appendicitis within a De Garengeot hernia that was managed with an open appendicectomy via a Lockwood incision. This case helps to illustrate the management considerations present for this rare clinical pathology and describes a method to effectively identify the hernia and resect the appendix.

Inguinal Hernia Containing an Inflamed Appendix: A Case of Amyand Hernia

Inguinal hernia is a prevalent surgical condition worldwide. The hernia sac typically contains the omentum and small intestine. However, it has been reported that some other organs might be seen, including the ovary, fallopian tube, bladder, and colon. We report the case of a 23-year-old man who presented to our emergency department with the complaint of scrotal pain for the last six days. The pain was mainly in the right side. There was no history of preceding trauma, and the pain developed gradually. He described the pain as having a sharp nature and was constant. He reported having a low-grade fever that resolved with the use of over-the-counter analgesics. There was no change in the urine or bowel habits. No penile discharge was reported. On examination, the patient had a low-grade fever and tachycardia. The patient appeared in pain and was not cooperative to have a complete genitalia examination. However, there was a positive cough impulse in the right inguinal region. The laboratory findings suggested the presence of inflammatory or infectious processes with elevated leukocytes, C-reactive protein, and erythrocyte sedimentation rate. The patient was prepared for emergency laparotomy for reduction of the hernia and resection of the appendix. During exploration, the appendix was reduced from the hernia sac. The appendix appeared edematous, with marked erythema representing acute appendicitis. The appendix was resected and the hernia sac was closed. The presence of an appendix in the inguinal hernia sac is very rare. The preoperative diagnosis of Amyand hernia, the inguinal hernia containing the appendix, can be difficult based on the clinical presentation. Early diagnosis is crucial to avoid the potential complications of Amyand hernia, including perforation and abscess formation. Imaging studies can establish the diagnosis of Amyand hernia with high accuracy and confidence.

Left-Sided Amyand Hernia: Case Report and Review of the Literature

Left-sided Amyand hernia is a rare condition that requires a high degree of clinical suspicion to correctly diagnose.

Amyand's hernia- outcome of nylon darn repairs after complicated appendix surgeries in a district hospital: case series

INTRODUCTION

Complicated appendix is a least expected sac content of inguinal hernias that always require appendix surgery and hernia repair. The current recommendations for posterior wall repairs however, continue to attract conflicting views as to which modality gives the best outcome in infected surgical wounds. New posterior wall repair methods with properties to withstand surgical site infections, minimise hernia recurrence, affordable and easy skill to acquire with a potential to be widely adopted are continuosly sort.

AIM

To determine the surgical outcomes of complicated Amyand Hernias repaired using the open tissue base Nylon Darn posterior wall re-enforcement method.

METHOD

A retrospective review of medical records of patients who had surgery for emergency inguinal hernia with intra-operative confirmation of complicated appendix in the hernia sac from January 2015 to December 2020 at the Margaret Marquart Catholic Hospital, Kpando were included. Data on age, sex, clinical presentation, surgical procedure, intra-operative findings, post operative complications were captured and presented as descriptive statistics.

RESULTS

Twelve out of 286(4.6%) repairs were complicated Amyand Hernias in patients aged 6weeks to 76-years{median age 54.5-years}. Most of them were adults, long-standing hernias. All diagnosis were made on-table. Surgical site infections was the most frequent complication in types III and IV AHs which resolved with antibiotic treatment.

CONCLUSION

The incidence of complicated AHs is higher and should be anticipated in surgeries for long-standing complicated inguinal hernias. Even though complications were significantly associated with longer hospital stay, no second procedure or mortality was recorded.

Hernia de Amyand. Reporte de caso y revisión de la literatura actual

Introducción. La hernia de Amyand es una condición clínica infrecuente que agrupa a dos patologías quirúrgicas habituales: apendicitis aguda y hernia inguinal; en esta entidad el apéndice vermiforme se encuentra en el interior del saco de una hernia inguinal. Su diagnóstico preoperatorio es difícil, por lo que debe tenerse en cuenta en casos de hernia inguinal antes de que se presente un proceso inflamatorio, el cual puede traer más complicaciones; además, aunque no existe un consenso para el manejo según las clasificaciones actuales, estas sirven de guía para una resolución quirúrgica oportuna. Presentación del caso. Hombre de 57 años procedente de la costa sur de Ecuador, quien consultó al servicio de emergencias de una institución de segundo nivel de atención por un cuadro clínico de 24 horas de evolución que inició con la aparición de una masa dolorosa e irreductible en la región inguinal derecha asociada a hiporexia. El paciente fue diagnosticado con hernia inguinal incarcerada y se le practicó una hernioplastia inguinal derecha en la que se encontró el apéndice y el ciego dentro del saco herniario; durante este procedimiento también se realizó apendicectomía y hernioplastia con técnica de Lichtenstein. El paciente fue dado de alta en buenas condiciones y en controles posteriores, a los 8 y 15 días de la cirugía, no presentó complicaciones. Conclusiones. La hernia de Amyand es una entidad cada vez más frecuente que tiene un difícil diagnóstico preoperatorio debido a su cuadro clínico inespecífico. Ante la sospecha de esta patología se deben realizar estudios de imagenología que ayuden a su visualización y orienten, junto con las clasificaciones actuales de este tipo de hernias, un manejo individualizado y temprano.

Amyand Hernia in a Pediatric Patient With Acute Perforated Appendicitis Undergoing Laparoscopy: A Brief Report and Literature Review

An 8-year-old male presented for evaluation of symptoms consistent with appendicitis. Upon laparoscopy, the patient was found to have appendicitis with a concomitant Amyand hernia. The latter pathology highlights a rare presentation of inguinal hernias in which the vermiform appendix herniates into the inguinal canal. Inguinal hernias are frequently encountered in pediatric populations; however, Amyand hernias have seemingly negligible incidence in all age demographics. These comprise roughly 1% of all diagnosed abdominal hernias. When seen in concurrence with appendicitis, the incidence is 0.13%. Recent literature has sought to classify types of Amyand hernias and criteria described by Losanoff and Basson is an attempt to guide surgical management. Although our management did not coincide with the proposed management above, the patient made a full recovery. In conclusion, Amyand hernias remain a rare entity that can be indistinguishable from routine inguinal hernias on clinical examination and management of Amyand hernia with appendicitis is not well defined.

Fascinating history of groin hernias: Comprehensive recognition of anatomy, classic considerations for herniorrhaphy, and current controversies in hernioplasty

Groin hernias include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias. Here, we summarize historical turning points, anatomical recognition and surgical repairs. Groin hernias have a fascinating history in the fields of anatomy and surgery. The concept of tension-free repair is generally accepted among clinicians. Surgical repair with mesh is categorized as hernioplasty, while classic repair without mesh is considered herniorrhaphy. Although various surgical approaches have been developed, the surgical technique should be carefully chosen for each patient. Regarding as interesting history, crucial anatomy and important surgeries in the field of groin hernia, we here summarized them in detail, respectively. Points of debate are also reviewed; important points are shown using illustrations and schemas. We hope this systematic review is surgical guide for general surgeons including residents. Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.

Incidental discovery of Amyand's hernia in an adult female: A case report

Introduction and importance

Amyand's hernia is a rare type of inguinal hernia with an incidence of about 0.1% of all inguinal hernias with most in occurring in childhood. It is characterized by the presence of the vermiform appendix within the hernia sac.

Case presentation

We report the case of 40-year-old female who underwent inguino-labial hernia repair with an incidental finding of a normal appendix within the sac; this was not predicted by the pre-operative ultrasound scan.

Clinical discussion

We recommend that a detailed ultrasound scan be done for all patients with an inguinal hernia to help to manage the patient timeously and safely.

Conclusion

We present a rare condition in a 40-year-old female with a right inguinal hernia, an Amyand's hernia.

•

We report a case of Amyand's hernia in a 40-year-old female who underwent inguinal hernia repair.

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A normal appendix was found in the sac and reduced without appendicectomy. Hernia repair without mesh was then performed.

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Ultrasound scan is an excellent technique to evaluate the inguinal region but remains operator dependent.

Etiology and surgical management of pediatric acute colon perforation beyond the neonatal stage

PURPOSE

Acute colon perforation is a pediatric surgical emergency. We aimed to analyze the different etiologies and clinical characteristics of acute non-traumatic colon perforation beyond the neonatal period and to identify surgical management and outcomes.

METHODS

This retrospective study included 18 patients admitted with acute colon perforation and who received surgical treatment.

RESULTS

Age of patients ranged between 1 month and 15 years. Five patients swallowed foreign objects (two swallowed magnets), two had colon perforation secondary to a malignant tumor (both colorectal adenocarcinoma) and two were iatrogenic (one prior colonoscopy, one air enema for intussusception). There was one perforation due to chemotherapy and Amyand's hernia respectively. The remaining seven patients had unknown etiologies; five of them were diagnosed with colitis. Fifteen (83.3 %) patients underwent open laparotomy, among which four attempted laparoscopy first. Three (16.7 %) patients underwent laparoscopic surgery. Fourteen (77.8 %) patients received simple suture repairs and four (22.2 %) received colonic resections and anastomosis. Four (22.2 %) patients received a protective diverting colostomy and three (16.7 %) received an ileostomy.

CONCLUSIONS

There is a wide range of etiology besides necrotizing enterocolitis and trauma, but a significant portion of children present with unknown etiology. Type of surgery elected should be dependent on the patient's etiology, disease severity and experience of surgeons.

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.

Revisiting Amyand's Hernia: A 20-Year Systematic Review

PURPOSE

Protrusion of the appendix within an inguinal hernia is termed an Amyand's hernia. A systematic review of case reports and case series of Amyand's hernia was performed, with emphasis on surgical decision-making.

METHODS

The English literature (2000-2019) was reviewed, using PubMed and Embase, combining the terms "hernia", "inguinal", "appendix", "appendicitis" and "Amyand". Overall, 231 studies were included, describing 442 patients.

RESULTS

Mean age of patients was 34 ± 32 years (adults 57.5%, children 42.5%). 91% were males, while a left-sided Amyand's hernia was observed in 9.5%. Of 156 elective hernia repairs, 38.5% underwent appendectomy and 61.5% simple reduction of the appendix. 88% of the adult patients had a mesh repair, without complications. Of 281 acute cases, hernial complications (76%) and acute appendicitis (12%) were the most common preoperative surgical indications. Appendectomy was performed in 79%, more extensive operations in 8% and simple reduction in 13% of cases. A mesh was used in 19% of adult patients following any type of resection and in 81% following reduction of the appendix. Among acute cases, mortality was 1.8% and morbidity 9.2%. Surgical site infections were observed in 3.6%, all of which in patients without mesh implantation.

CONCLUSION

In elective Amyand's hernia cases, appendectomy may be considered in certain patients, provided faecal spillage is avoided, to prevent mesh infection. In cases of appendicitis, prosthetic mesh may be used, if the surgical field is relatively clean, whereas endogenous tissue repairs are preferred in cases of heavy contamination.

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.

Appendiceal hernia: an extremely rare condition

Appendix-associated hernias are extremely rare. They have been described sporadically in the literature, mostly as inguinal hernias. Appendix-associated incisional hernias are even more unusual. High clinical awareness is needed as complications can arise if misdiagnosis or delay occurs. We present an 80-year-old man with acute appendicitis in an incisional hernia. After successful surgery, the patient made a full recovery.

Gangrenous appendicitis in Amyand's hernia: Surgical approach under local anesthesia. Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Amyand hernia is a rare disease seen in approximatively 1% of all hernias, complications of it, like acute appendicitis, or perforated appendicitis are even more rare, about 0.1%. Its diagnosis is very difficult in the preoperative period: it is usually an incidental finding.

CASE PRESENTATION

We report an unusual case of perforated gangrenous appendicitis with peri-appendicular abscess occurring in an irreducible Amyand's hernia. An 80-year-old male, with chronic obstructive disease and pulmonary emphysema, atrial fibrillation, acute myocardial infarction, underwent urgent surgery, under local anesthesia, for right incarcerated inguinoscrotal hernia. He was found to have a perforated gangrenous appendicitis with peri-appendicular abscess within a right indirect inguinal hernia sac. Appendicectomy and Bassini's hernia repair were performed under local anesthesia without any complications.

CLINICAL DISCUSSION

The treatment of Amyand's hernia is not standardized. The current generally accepted algorithm for Amyand's hernia is essentially contingent on the appendix's condition within the hernia sac.

CONCLUSION

Appendectomy and primary herniorrhaphy, under local anesthesia, for type 3 of Amyand's hernia, is a safe procedure and easy to perform and, if confirmed by further study, could be part of every surgeon's knowledge.