|Year : 2019 | Volume
| Issue : 2 | Page : 70-73
Amyand hernia: A case report and literature review
Tian Jiyu, Wei Shibo, Qin Dailei, Guo Zhiwei, Yan Yuhao, Li Xian, Li Hangyu
Department of Hernia and Abdominal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
|Date of Submission||18-Dec-2018|
|Date of Acceptance||30-Jan-2019|
|Date of Web Publication||10-May-2019|
Prof. Li Hangyu
Department of Hernia and Abdominal Surgery, The Fourth Affiliated Hospital of China Medical University, No. 8 Chong Shan East Road, Huanggu District, Shenyang
Source of Support: None, Conflict of Interest: None
Amyand hernia is a rare form of inguinal hernia wherein the appendix is in the hernial sac. Moreover, the incidence of Amyand hernia is reportedly three times higher in children than in adults. Here, we report a case of Amyand hernia in the right groin of a 55-year-old patient admitted to our hospital. We describe our approach to the diagnosis and treatment of Amyand hernia in this case. Altogether, we conclude that reasonable individualized diagnosis and treatment for Amyand hernia according to the patient's conditions is warranted in such cases.
Keywords: Amyand hernia, Bassini, inguinal hernia
|How to cite this article:|
Jiyu T, Shibo W, Dailei Q, Zhiwei G, Yuhao Y, Xian L, Hangyu L. Amyand hernia: A case report and literature review. Int J Abdom Wall Hernia Surg 2019;2:70-3
| Introduction|| |
Amyand hernia is an inguinal hernia containing a normal, infected, or perforated appendix. Amyand hernia accounts for 0.19%–1.7% of the total inguinal hernia incidence. The incidence of Amyand hernia is reportedly three times higher in children than in adults. To the best of our knowledge, as few cases of Amyand hernia have been reported, there is no consensus on its treatment.
| Case Report|| |
A 55-year-old man presented with a reducible mass in the right groin for 4 months. Physical examination yielded a mass measuring 4 cm × 5 cm in the groin; the mass was nontender, soft, and had a smooth surface. If the right groin outer ring was enlarged, the mass could be lowered into the scrotum. No redness or signs of rupture were detected. The body mass index of patient is 22.2 (kg/m2), and he had no history of appendicitis.
Based on the preoperative color Doppler ultrasound of both inguinal regions indicating a low-echo zone of 6.3 cm × 2.5 cm in the right inguinal region [Figure 1], the patient was diagnosed with right inguinal hernia. Abdominal computed tomography (CT) is not routinely performed for inguinal hernia; therefore, Amyand hernia was not detected preoperatively. Informed consent for surgical treatment was obtained from the patient and his relatives.
He underwent an elective tension-free hernia repair and appendectomy using an oblique incision along the skin fold of the right inguinal region under the spinal block. Upon isolation, the inguinal canal posterior wall was damaged, and the transverse fascia was missing, indicating an intraoperative diagnosis of Type III hernia. When sac isolation was continued, the sac was enlarged, with spermatic cord hydrocele and lipoma, which were removed. The inguinal region anatomy was complex and not clearly identifiable. The sac was separated and contained mesangial tissues. The sac wall was continuously isolated until the right lower abdomen. The sac wall (length, 10 cm) was found as the mesoappendix [Figure 2], with a inflammation appendix as hernia content. After incision protection, the sac wall was cut, and appendectomy was performed. The sac was sutured with 000 absorbable lines and replaced into the preperitoneal space after excess removal. Bassini repair was performed; PDS II (polydioxanone) (No. 0) sutures were used to suture the upper and lower abdomen transverse fascia at the inner ring until only one forefinger could pass. No. 0 absorbable lines were used behind the spermatic cord to intermittently suture the obliquus internus abdominis, inferior border of transverse abdominis, and conjoint tendon to the corresponding inguinal ligament. The distal end of the medial external oblique aponeurosis was sutured with the lacunar ligament (one suture). After external oblique aponeurosis closure using the No. 000 absorbable line, we examined whether the inferior wall of the inguinal canal was sutured firmly and closed the incision in layers.
Histopathologic examination of the appendix: acute appendicitis. The patient was intravenously administered cephalosporins (2.0 g, twice daily) for three days; recovery was uneventful. We let him stay in bed for 3 days, to ensure the solid suture of Bassini herniorrhaphy, supplemented with anticoagulation therapy (lower limbs pressure therapy) to prevent lower limbs deep venous thrombosis. At the 4th day after surgery, we let him doing the postoperative recovery at home for 4 days until discharge because of the pain and discomfort feeling. Postoperatively, inguinal pain reduced, but the patient felt slight discomfort during activity on discharge (7-day postsurgery) likely related to the traditional repair method. No recurrence was noted at the 1-month follow-up.
| Discussion|| |
Amyand hernia is characterized by low incidence, difficult diagnosis, and diverse intraoperative conditions. Because of the specificity of the hernia content, when the Amyand hernia is found during the surgery, the operating area conditions and anatomy may become complicated sometimes. Therefore, early diagnosis and selecting an effective treatment approach are imperative in such cases.
Amyand hernia is mostly confirmed during surgery; preoperative imaging-based diagnosis is rare. CT is the only imaging technique with high sensitivity for Amyand hernia; however, it is not routinely performed for hernia patients. Therefore, medical history taking and abdominal examination are important in these patients. If patients with inguinal hernia presenting with inguinal discomfort, tenderness around McBurney's point, abdominal appendicitis signs, or history of chronic appendicitis or recurrent pain in the right lower abdomen, Amyand hernia should be suspected.
Appendectomy is determined according to the hernia type. In 2008, Losanoff and Basson proposed a classification method for adult Amyand hernia, with corresponding treatment plans. Type I is hernia with normal appendix, requiring patch repair with or without appendectomy. Type II is hernia with appendicitis, but inflammation is confined to the hernia sac, requiring appendectomy with bio-patch or simple repair. Type III is hernia with appendicitis and peritonitis, requiring laparotomy; right hemicolectomy and orchiectomy may be feasible based on patient condition. Type IV is hernia with severe intra-abdominal complications, which should be treated according to patient condition after laparotomy. In children, high ligation of the hernia sac with or without appendectomy is preferred.
Intra-abdominal or surgical site infection is not recommended to use mesh for repair. Infected patches can aggravate the body's rejection response, requiring a second surgery for removal. Patch repair was therefore not recommended in Amyand hernia with appendicitis or abdominal infection cases. However, patch repair has reportedly succeeded in some Type II and Type III cases [Table 1].,,,
Bio-patches have certain advantages; they cause less inflammatory responses and reduce allogeneic reactions. Bio-patches have also been used to treat Amyand hernia. Generally, bio-patches are used in Type II or III hernia or at the infected surgical site, but appendectomy and local infection control are vital. Otherwise, the infection source will persist, causing repeated local inflammation, resulting in patch removal requirement or worse consequences. Bio-patches can be enveloped by collagen and other stromal cells, causing delayed absorption after 4 to 7 months, contributing to inguinal hernia repair and reducing recurrence. After bio-patch implantation, fibrous tissue deposition occurs during which a typical scar forms due to normal wound healing, mimicking fascia regeneration., No recurrence, combined complications, or infections have been reported after bio-patch repair for Amyand hernia, but its therapeutic effect cannot be fully ascertained due to sample sizes and lack of long-term follow-up data.
Perioperative antibiotic use reduces the risk of complications such as wound infection. Sharma et al. reported that 18 cases of Amyand hernia treated with only antibiotics developed one-tenth the complications seen in other studies. Perioperative antibiotic use thus may be effective.
Our patient did not appear to have symptoms of appendicitis. However, during the surgery the appendix showed significantly appendicitis might develop appendicitis due to compromised blood supply, and appendectomy was still performed followed by nonpatch repair. However, patch repair is still considerably controversial. Although bio-patches can partially compensate for the disadvantages of synthetic patches, their reliability is still uncertain. Overall, reasonable individualized diagnosis and treatment for Amyand hernia according to the patient's conditions is warranted in such cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]