key: cord-0025830-11e8kxmb
authors: Corvatta, Franco; Rodriguez Santos, Fanny; Mazzini, Federico; Fuente, Ignacio
title: Amyand's hernia complicated with appendicitis
date: 2021-08-23
journal: Rev Fac Cien Med Univ Nac Cordoba
DOI: 10.3105310.31053/1853.0605.v78.n3.30705
sha: 2fa09c74d63f2248d14b66c672e4f7361c86672b
doc_id: 25830
cord_uid: 11e8kxmb

INTRODUCTION: The finding of a vermiform appendix within the peritoneal sac of an indirect inguinal hernia occurs in approximately 1% of cases. However, the presence of appendicitis within an inguinal hernial sac is found only in 0.08% of the general population. CASE REPORT: We present the case of a 58-year-old male patient that was admitted with abdominal pain associated with a small non-reducible right groin mass. DISCUSSION: To establish the correct diagnosis preoperatively, an abdominal and pelvic CT scan is mandatory. CONCLUSION: Acute appendicitis in an Amyand's hernia is a very rare entity that can be easily misdiagnosed preoperatively. CT is extremely useful in reaching the correct preoperative diagnosis.

The finding of a vermiform appendix within the peritoneal sac of an indirect inguinal hernia was first described by De Garengeot in 1731 (1) . This incidental finding occurs in approximately 1% of cases of inguinal hernia (2) , however, the presence of appendicitis within an inguinal hernial sac is found only in 0.08% of the general population (3). In 1735 Claudius Amyand performed the first appendectomy through an inguinal herniotomy, giving the name to this entity (1).

A 58-year-old male patient with unremarkable past medical history was admitted to the emergency department for abdominal pain. Physical examination revealed a distended abdomen without peritoneal signs. A small non-reducible right groin mass with severe tenderness to palpation was noted. After clinical evaluation, a laboratory was performed showing a white blood cell count of 16.500/mm3 (normal range: 4.000-11.000/mm3). A Computed tomography (CT) showed right inguinal hernia with an incarcerated, inflamed vermiform appendix with an air-fluid level (Figure 1 ). Based on the presumptive diagnosis of acute appendicitis, we carried out a laparoscopic approach. During exploration, we found the appendix protruding through the right deep inguinal ring (Figure 2 A-B) . As a remarkable note, we found a left inguinal hernia with no signs of complications. The herniated appendix was reduced into the abdominal cavity, evidencing an 8 x 6 cm appendix (Figure 2 

A standard laparoscopic appendectomy was performed. The postoperative course was uneventful and the patient was discharged the following day. The pathology report was consistent with acute phlegmonous appendicitis. 

The finding of an inflamed appendix within an inguinal hernial sac occurs in less than 0.1% of cases of the general population (3). This entity has been reported in a variety of ages, from 3 weeks to 88 years old. Males are more often affected by inguinal hernias. However, the concomitant occurrence of acute appendicitis in the sac of a crural hernia is more frequent in females (4) . The clinical presentation does not differ from an acute appendicitis, with abdominal pain and tenderness in the lower right quadrant, associated with a non-reductible groin mass due to an inguinal or femoral hernia. Differential diagnosis has to be made with epiploic strangulation and Richter's hernia (4) . The diagnosis is rarely established preoperatively in patients without a palpable groin mass. Imaging studies such as abdominal and pelvic CT can demonstrate a blind-ending tubular structure arising from the caecum which extends into the inguinal sac. A dilated lumen, enhanced and thickened wall, and striaton of adjacent peri-appendiceal fat are suggestive signs of acute appendicitis. Ultrasonography (USG) can also demonstrate the extension of the appendix into the inguinal sac, and in case of acute inflammation, the appendix is dilated, non-compressible, thickened and hypervascular. Therefore, USG is an useful radiation-free imaging modality for children and pregnant women (5) . Although abdominal CT may be helpful in reaching the correct diagnosis, in the vast majority of the cases the diagnosis is confirmed intraoperatively (6) . Regarding the treatment of complicated Amyand´s hernias, Losanoff et al established a classification in order to improve their management. In the presence of an Amyand's hernia complicated with acute appendicitis, reduction of the hernia with mesh-free repair of the inguinal floor associated with appendectomy is recommended (7) . However, an individualized approach must be performed since it depends on the state and integrity of the appendix. Published evidence regarding appendicitis in an Amyand hernia describes a combined treatment of appendectomy plus hernia repair (4, 7) . In the present case, inguinal repair was not performed due to small size of the right defect in addition to the finding of bilateral inguinal hernia. Considering that the patient will undergo a second surgery for left inguinal hernia and taking into account that the surgery was carried out during the COVID-19 outbreak and a reduced surgery time was sought, we decided to only reduce the content of the inguinal hernia and perform the laparoscopic appendectomy.

Acute appendicitis in an Amyand's hernia is a very rare entity that can be easily misdiagnosed preoperatively. CT is extremely useful in reaching the correct preoperative diagnosis.

The information contained in this article is only the responsibility of the authors.

No conflict of interest to disclose.

Originality of the work This article is original and has not been submitted for publication in whole or in part to any other scientific journal.

The participants in this work cede copyright to the Universidad Nacional de Córdoba for publication in the Revista de la Facultad de Ciencias Médicas and for any translations that may be necessary.

Informed consent statement: Informed patient consent was obtained for case publication.

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