|Year : 2019 | Volume
| Issue : 4 | Page : 157-158
Amyand's hernia without appendicitis; case report with 4-year follow-up
Keerthi Rajapaksha1, Samitha Rochana Samaraweera2
1 Department of General Surgery, Navy General Hospital; Department of Surgery, Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
2 Department of General Surgery, Navy General Hospital, Colombo, Sri Lanka
|Date of Submission||12-Jul-2019|
|Date of Decision||15-Sep-2019|
|Date of Acceptance||19-Sep-2019|
|Date of Web Publication||22-Oct-2019|
Dr. Keerthi Rajapaksha
91/B/3, Raddoluwa, Seeduwa
Source of Support: None, Conflict of Interest: None
Amyand's hernia (AH) is a rare condition where the vermiform appendix is present in the inguinal hernia sac. Controversies exist regarding its management, particularly when the appendix is uninflamed. The current case report describes a 76-year-old male patient who was found having AH without appendicitis during the right side inguinal hernia repair. The patient underwent inguinal herniotomy and mesh repair without appendicectomy. There was no appendicitis or recurrence of hernia during the 4-year follow-up. Hence, we conclude that the appendicectomy is not routinely required in AH, if the appendix is uninflamed.
Keywords: Amyand's hernia, hernia, vermiform appendix
|How to cite this article:|
Rajapaksha K, Samaraweera SR. Amyand's hernia without appendicitis; case report with 4-year follow-up. Int J Abdom Wall Hernia Surg 2019;2:157-8
| Introduction|| |
Amyand's hernia (AH) accounts for 1.7% of inguinal hernias. Most of the time, AH is found on the right side, but occasionally on the left side. If the patient presents without acute symptoms for hernia repair, the presence of appendix was found during surgery. Rest of the surgery should be planned according to the state of the appendix. Appendicectomy for inflamed appendix is unarguable. However, does appendicectomy is required if the appendix is uninflamed? The current study describes a case of AH with uninflamed appendix, which was managed without appendicectomy with the 4-year postoperative follow-up.
| Case Report|| |
A 76-year-old male, known patient with hypertension, presented with a painless lump in the right hemiscrotum, which gradually increased in size over several months and is now irreducible. There was no tenderness. Cough impulse was transmitted to the lump and diagnosed as a right-sided inguinoscrotal hernia. During the open repair of inguinal hernia under spinal anesthesia, hernia was found to be an indirect inguinal hernia. Vermiform appendix was found among omental contents in the hernia sac, and diagnosis of AH was made [Figure 1]. Appendix was macroscopically uninflamed, and there were no adhesions or incarceration. All the contents including appendix were reduced into the peritoneal cavity. Tension-free mesh repair was performed with polypropylene mesh. Surgery was uncomplicated, and the postoperative recovery was uneventful. Medical records of the patient were followed up at 4 years, and there was no recurrence of hernia or development of appendicitis during this period.
|Figure 1: Amyand's hernia, vermiform appendix (blue arrow) among the omental contents (yellow arrow) in the indirect sac (black arrow)|
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| Discussion|| |
Claudius Amyand – first described and performed the surgery for the presence of appendix in the hernia sac in 1975, and the condition bears his name. AH is found in up to 1.7% of cases. It is commonly seen in right-sided hernias because of the anatomical position of the appendix. Left-sided cases are even rarer. AH is extremely difficult to be identified preoperatively in most cases and can be an incidental finding during the surgery as in our case. If appendix was found to be inflamed during the operation, appendicectomy should be performed to prevent septic complications. However, appendicitis in AH accounts for <0.1% of cases.
Does appendicectomy is required for the patients without appendicitis in AH?
There is a theoretical risk of infection of prosthetic material used to reinforce the hernia defect if appendicectomy is performed at the same time. Tissue repair can be an alternative for prosthetic meshes in hernia repair when the risk of infection is high. However, tissue repair was associated with higher recurrence rates with less experienced hands. Further, preservation of uninflammed appendix is preferred, as it can be used for surgical replacement of extrahepatic bile ducts, ureters, and as a conduit to the bladder in future surgeries. However, on the basis of “manipulation of appendix may increase the risk of future appendicitis,” proponents perform appendicectomy even in the absence of appendicitis in AH. Laparoscopic appendicectomy with open mesh repair is attempted and documented with success for AH without appendicitis. However, this approach is relatively complex and may incur additional cost. Long-term follow-up data are required to answer the question whether the appendicectomy is really indicated for uninflamed appendix in the AH. Long-term follow-up data are lacking in majority of published cases of AH.
Our patient described in this study did not undergo appendicectomy during hernia repair. Mesh repair of inguinal hernia was performed without complication. During 4-year follow-up, the patient did not develop appendicitis. Hence, the most simple way to treat AH without appendicitis is to perform mesh repair of inguinal hernia after reducing the appendix and content into the peritoneal cavity. Further, authors are encouraged to include long-term follow-up data with their cases to solve the controversies in the future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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