Amyand Hernia With Acute Appendicitis: A Rare Type of Hernia

A hernia is an abnormal protrusion of an organ or tissue from its containing cavity. Inguinal hernia is the most common type of abdominal hernias. The presence of the appendix within the inguinal hernial sac is a rare occurrence. We present the case of a 41-year-old man, with no previous surgical history, who presented to the emergency department with a right-sided painful groin swelling. The swelling was associated with nausea, vomiting, anorexia, and fever. Initial laboratory investigation revealed leukocytosis and elevated C-reactive protein and erythrocyte sedimentation rate. A computed tomography (CT) scan demonstrated the presence of an inflamed appendix with an inguinal hernia. The patient underwent laparoscopic repair of the hernia with appendectomy. The patient tolerated the procedure without any complications. Amyand hernia with acute appendicitis is a very rare surgical condition. Clinicians should have a high index of suspicion for Amyand hernia with appendicitis when they encounter a patient with groin mass with laboratory markers indicating an inflammatory process.


Introduction
A hernia is an abnormal protrusion of an organ or tissue from its containing cavity.Inguinal hernia repair remains one of the most commonly performed surgeries worldwide.It accounts for 80% of the abdominal wall hernias.The lifetime prevalence of inguinal hernia reaches over 25% [1].Surgical repair is the only cure for such hernias.The hernia is termed "incarcerated" if the contained organ is non-reducible.Besides, strangulated hernia refers to a hernia with a compromised blood supply, leading to ischemia and necrosis.The hernial sac often contains omental fat or bowel [2].A significant array of surgical approaches has been described for the management of inguinal hernia.Here, we report the case of a middle-aged man with an Amyand hernia, an inguinal hernia containing the appendix, who was managed successfully by laparoscopic repair.Laparoscopic surgery has diagnostic and therapeutic roles in Amyand hernia.A limited number of cases have been reported where the laparoscopic approach was used for Amyand hernia.The first case of laparoscopic repair of Amyand hernia was described by Vermillion et al. in 1999 [3].

Case Presentation
We present the case of a 41-year-old man who presented to the emergency department complaining of swelling in his right groin for two weeks' duration.He reported that the swelling became painful and nonreducible for the last two days.The pain was associated with decreased appetite and subjective fever.The patient reported having nausea and recurrent episodes of vomiting in the last 24 hours.The patient did not undergo any previous surgeries.His past medical history was remarkable for well-controlled asthma.He was a non-smoker and never drinks alcohol.The patient worked as a school teacher.He has a significant family history of sickle cell disease.
Upon examination, the patient appeared in distress due to the pain.His vital signs were as follows: a temperature of 38°C, a pulse rate of 110 beats per minute, blood pressure of 118/95 mmHg, and respiratory rate of 14 breaths per minute.There was a swelling in the right inguinal region, measuring 4 x 6 cm.It was oval in shape and had a smooth surface with an evident expansile cough impulse.The swelling was nonreducible with slightly erythematous and warm overlying skin.
In view of the clinical features, the diagnosis of incarcerated inguinal hernia was established.The patient underwent a pre-operative laboratory investigation, which revealed leukocytosis with neutrophilia and left shift, elevated erythrocyte sedimentation rate and C-reactive protein, and normal renal and hepatic profiles (Table 1).The patient underwent an abdominal computed tomography (CT) scan to identify the content of the hernia and diagnose any possible complications.CT demonstrated a right-sided inguinal hernia that contained the cecum and a rim-enhancing structure that represented an inflamed appendix with surrounding inflammatory changes (Figure 1).Such radiological findings conferred the diagnosis of Amyand hernia with acute appendicitis.

CT, computed tomography
The patient was prepared for an emergency laparoscopy operation for the reduction of the inguinal hernia.
The patient was administered general anesthesia and was placed in a supine position.Pneumoperitoneum was established.The diagnostic evaluation revealed a right inguinal hernia containing an inflamed appendix.
An appendectomy was performed, and the appendix was removed in a sterile bag.The hernia was repaired using the totally extraperitoneal approach with mesh repair.No complications were encountered during the operation.The estimated blood loss was 5 mL and the total operative time was 120 minutes.The patient had an uneventful recovery and was discharged on the fifth postoperative day.The histopathological examination of the appendix confirmed the diagnosis of acute appendicitis.

Discussion
We described the case of a middle-aged man with an Amyand hernia and acute appendicitis that was managed successfully via a laparoscopic approach.The occurrence of the appendix within the sac of inguinal hernia is very rare.It was first described by Claudius Amyand in 1736 who successfully performed appendectomy in a young child with a right inguinal hernia [4].Amyand hernia represents less than 1% of inguinal hernias [2].Furthermore, it is very rare for patients with Amyand hernia to present with concomitant Amyand hernia and acute appendicitis.In the present case, the patient was found to have neutrophilic leukocytosis indicating an inflammatory process.However, such findings are non-specific.
In the present case, the appendix was found to be inflamed as per the CT findings.The presence of appendicitis within the hernia sac has essential surgical implications.For instance, the surgeon needs to perform an appendectomy instead of a simple hernia repair in the case of Amyand hernia with acute appendicitis.It should be noted that the Amyand hernia may contain a normal or an inflamed appendix.However, the herniated appendix is at a higher risk of developing an infection.It is postulated that the narrow hernial neck causes restricted blood flow, leading to edema and inflammation [2].
In contrast to the present case, Amyand hernia is three times more prevalent among children than adults.However, it may occur at any age and has been reported in patients ranging from neonates to the elderly [5].It is much more common among male patients.If Amyand hernia develops among female patients, it tends to be found among postmenopausal women [6].
Early diagnosis and management of Amyand hernia are crucial.The reported mortality rate from Amyand hernia may reach up to 30% [7].However, the mortality is substantially reduced as earlier Amyand hernia was often diagnosed incidentally during surgery.The widespread use of advanced imaging allowed the preoperative diagnosis of Amyand hernia with acute appendicitis.Since inguinal hernia is a clinical diagnosis, patients often undergo surgical repair without the need for prior radiological imaging.In the present case, however, the patient was found to have abnormal laboratory markers suggestive of an inflammatory process, which mandated further investigations.We performed a CT scan to rule out any intra-abdominal infection.CT remains the imaging modality of choice for patients with groin mass.However, there are several cases in the literature where the Amyand hernia was diagnosed via ultrasound examination [8].
There are controversies about the optimal surgical approach [9].Several factors should be taken into consideration regarding the use of mesh for the repair of the hernia, including the patient's age, comorbidities, life expectancy, and presence of complicated appendicitis.Many authors did not recommend performing appendectomy in Amyand hernia if the appendix was normal or mildly congested since it may increase the risk of septic complications [10].In our case, the appendix was grossly inflamed with a significant risk of perforation.We used a tension-free mesh repair as there was no evidence of peritoneal sepsis.

Conclusions
Amyand hernia with acute appendicitis is a very rare surgical condition.Clinicians should have a high index of suspicion for Amyand hernia with appendicitis when they encounter a patient with groin mass with laboratory markers indicating an inflammatory process.A CT scan is essential in making the preoperative diagnosis.The laparoscopic approach is feasible and safe for the repair of the Amyand hernia with acute appendicitis.

FIGURE 1 :
FIGURE 1: CT imageAxial image of CT scan of the abdomen demonstrating a right inguinal hernia with a rim-enhancing structure representing the inflamed appendix (arrow).