Amyand's Hernia with Periappendicular Abscess

대한외과학회지：제 75 권 제 5 호

□ 증 례 □

Vol. 75, No. 5, November, 2008

355

Corresponding to: Shin Kon Kim, Department of Surgery, Chonnam National University Medical School, 671, Jebong-ro, Dong-gu, Gwangju 501-757, Korea. Tel: 062-220-6456, Fax: 062-227-1635, E-mail: [email protected]

Received April 19, 2008, Accepted May 7, 2008

Fig. 1. Abdominal and pelvic radiographs (erect view). There are no signs of mechanical obstruction.

Amyand's Hernia with Periappendicular Abscess

Department of Surgery, Chonnam National University Medical School, Gwangju, Korea

The presence of a vermiform appendix in an inguinal hernia is known as Amyand's hernia. It is rare condition that occurs in about 0.51% of the cases of inguinal hernia. Appendicitis within an Amyand's hernia is found in 0.10% of all forms of external hernia sacs. It is often misdiagnosed as a strangulated inguinal hernia. We experienced a case of Amyand's hernia with a periappendicular abscess within a right inguinal hernia sac in a 71-year-old male patient. Combined appendectomy and Bassini's herniorrhaphy were performed. The patient had an uncomplicated postoperative course and he was discharged 8 days after admission. (J Korean Surg Soc

Key Words: Vermiform appendix, Amyand's hernia, Periappendicular abscess

INTRODUCTION

Inguinal hernia may display very unusual sac contents.

Ovary, fallopian tube, urinary bladder, incarcerated bladder, diverticula, large bowel diverticula with the form of diverticulitis or abscess and Meckel's diverticulum (Littre hernia) have been rarely reported.(1,2) The presence of the appendix within an inguinal hernia has been referred to as "Amyand's hernia" to honour Claudius Amyand, surgeon to King Geroge II. Amyand was the first to describe the presence of a perforated appendix within the inguinal hernial sac of an 11-year-old boy and performed a successful transherniotomy appendectomy.(3) We report a case of Amyand's hernia with periappendicular abscess in a right inguinal hernia with a brief review of the literature.

CASE REPORT

A 71-year-old male patient presented to the emergency

department with an 8-day history of pain and a mass in the right inguinoscrotal region. Clinical examination revealed a right sided, irreducible indirect inguinal hernia.

Physical examination revealed mild tenderness to palpation

in right lower quadrant, along with a palpable and tender

irreducible right inguinal hernia. Vital signs on admission

were unremarkable, and laboratory evaluation revealed

10,600/mm

of white blood cell count and 14.7 mg/dl of

CRP. Abdominal and pelvic plain radiographs were

356

Fig. 2. Abdominal and pelvic CT scan. (A) There are concentric wall thickening of the cecum and pericecal fat infiltration. (B) The vermiform appendix is inflamed and herniated into the right inguinal canal. (C) Fluid collection is seen in the right scrotal region.

negative for signs of obstruction or free intraperitoneal air (Fig. 1). CT scan of the abdomen and pelvis demonstrated a dilated appendix, with significant periappendicular inflammation, fluid collection and a moderate amount of adjacent fat stranding with extension into the right inguinoscrotal region (Fig. 2). Operative findings included inflammatory swelling of the appendix with purulent fluid collection in the right inguinoscrotal hernia sac.

Appendectomy with drainage of scrotal fluid collection through transherniotomy and Bassini's herniorrhaphy were performed. Pathologic examination confirmed the diagnosis of periappendicular abscess. The patient had an uncomplicated postoperative course and was discharged 8 days after admission.

DISCUSSION

Claudius Amyand (1680∼1740) was Sergeant-Surgeon to King George II, Fellow of the Royal Society, the first Principal Surgeon to the Westminster Hospital, and the founder and first Principal Surgeon to St. George's Hospi- tal.(3) Operating on December 6, 1735 at the St. George's Hospital, London on a 11-year-old boy with a fistula dis- charging feces in the groin, he found an inguinal hernia containing a perforated appendix. The perforation was caused by a pin in the appendix. The case was reported by him in the Philosophical Transactions of the Royal Society in 1736.(4) The term Amyand's hernia has been used variously to refer to occurrence of an inflamed appendix within an inguinal hernia,(5) a perforated appendix within an inguinal hernia,(4) or a non-inflamed

appendix within an irreducible inguinal hernia.

Vermiform appendix was found in 0.51% and acute appendicitis was found in 0.10% of groin hernia sacs.(1) Most of the cases occur on the right side as a consequence of the normal anatomical position of appendix but it has also been reported on the left side in cases with the situs inversus, intestinal malrotation or a mobile cecum.(6,7) An extensive literature search revealed several reported cases of left sided Amyand's hernia.(8-10)

The majority of the reported cases present with the features of an obstructed or strangulated inguinal hernia.

Even acute appendicitis or perforation of the appendix within the sac stimulates perforation of the intestine within the hernia, some patients don't have specific symptoms or signs. Due to these facts it is very difficult to reach a clinical diagnosis of Amyand's hernia preoperatively. In fact, the diagnosis is made intraoperatively as the patient undergoes surgical exploration for a complicated inguinal hernia. A preoperative CT scan of the abdomen could be helpful for diagnosis, but this is not a routine practice after the clinical suspicion of a complicated inguinal hernia.(5) Most of the published cases have been reported as appendicitis incarcerated in a hernia. It is difficult to determine whether a primary visceral inflammation, which could be referred to as appendicitis, is the pathological mechanism, or if the primary event is strangulation of the herniated appendix, leading subsequently to ischemic necrosis and secondary inflammation.(11)

The surgical options for dealing with the appendix in an Amyand's hernia depend on the mode of presentation.

The presence of a normal appendix does not require an

Chan Yong Park, et al：Amyand's Hernia with Periappendicular Abscess

357

appendectomy to be performed, whereas the presence of an inflamed appendix necessitates its removal, with primary repair using the same incision.(12,13) The presence or absence of inflammation of the appendix is a very important determinant of appropriate treatment. If inflammation of the organ and incipient necrosis are present, a transherniotomy appendectomy should be per- formed. The presence of pus or perforation of the organ is also an absolute contraindication to the placement of mesh for hernia repair. Associated intra-abdominal abscesses, if present, may be dealt with either percuta- neously or by open drainage. The majority of the authors agree that a normal appendix within the hernia sac does not require appendectomy, and that every effort should be made to preserve the organ found in the hernia sac for an uneventful postoperative course.(6,12,14,15)

Unfortunately, the presence of elevated white blood cell count is not reliable for identifying Amyand's hernia.

Our case showed the utility of CT of the acute abdomen and pelvis in revealing a previously unsuspected diagnosis.

As a result of the CT findings in our patient, we were able to anticipate the need for combined appendectomy and hernia repair.

At surgery, if the peritoneal cavity is uncontaminated it must be protected from contamination.(5)

We did not use a synthetic mesh, because the prosthetic material can increase the inflammatory response, result in wound infection and possible appendiceal stump fistula.

In case of incarcerated femoral hernia including a gangrenous appendix, combined appendectomy and McVay hernia repair is recommended.(16)

It is not surprising that reported complications of Amyand's hernia are common, since the diagnosis of acute appendicitis is not anticipated prospectively. Our patient had the benign clinical course.

Amyand's hernia with periappendicular abscess is very rare. The fact that the majority of Amyand's hernia present as a complicated inguinal hernia makes preoperative diagnosis difficult. It demands that surgeons consider this condition in their differential diagnosis and so they are able to offer appropriate treatment. The CT scan of the

acute abdomen and pelvis revealed a previously un- suspected diagnosis. As a result of the CT findings in our patient, we were able to anticipate the need for combined appendectomy and hernia repair. In this case, we thought that the proper treatment is combined appendectomy and hernia repair without the use of any synthetic mesh.

REFERENCES

1) Gurer A, Ozdogan M, Ozlem N, Yidirim A, Kulacoglu H, Aydin R. Uncommon content in groin hernia sac. Hernia 2006;10:

152-5.

2) Greenberg J, Amell TD. Diverticular abscess presenting as an incarcerated inguinal hernia. Am Surg 2005;71:208-9.

3) Hutchinson R. Amyand's hernia. J R Soc Med 1993;86:104-5.

4) Amyand C. An inguinal rupture, with a pin in the appendix caeci encrusted with stone; and some observations on wounds in the gut. Phil Trans R Soc Lond 1736;39:329-42.

5) Luchs JS, Halpern D, Katz DS. Amyand's hernia: prospective CT diagnosis. J Computer Assisted Tomog 2000;24:884-6.

6) Gupta S, Sharma R, Kaushik R. Left-sided Amyand's hernia.

Singapore Med J 2005;46:424-5.

7) Pellegrino JM, Feldman SD. Case report: acute appendicitis in an inguinal hernia. N J Med 1992;89:225-6.

8) Bakhshi GD, Bhandarwar AH, Govila AA. Acute appendicitis in left scrotum. Indian J Gastroenterol 2004;23:195.

9) Gupta S, Sharma R, Kaushik R. Left-sided Amyand's hernia.

Singapore Med J 2005;46:424-5.

10) Gupta N, Vinay Wilkinson TR, Wilkinson A, Akhtar M.

Left-sided incarcerated Amyand's hernia. Indian J Surg 2007;

69:17-8.

11) Weir CD, Doan SJ, Lughlin V, Diamond T. Strangulation of the appendix in a femoral hernia sac. Ulster Med J 1994;

63:114-5.

12) House MG, Goldin SB, Chen H. Perforated Amyand's hernia.

South Med J 2001;94:496-8.

13) D'Alia C, LoSchiavo MG, Tonante A, Taranto F, Gagliano E, Bonanno L, et al. The Amyand's hernia: case report and review of the literature. Hernia 2003;7:89-91.

14) Bleichrodt RP, Simmermacher RK, van der Lei B, Schakenraad JM. Expanded polytetrafluoroethylene patch versus polypro- pylene mesh for the repair for the reapir of contaminated defects of the abdominal wall. Surg Gynecol Obstet 1993;176:

18-24.

15) Franko J, Raftopoulos I, Sulkowski R. A rare variation of Amyand's hernia. Am J Gastroenterol 2002;97:2684-5.

16) Jo TW, Chang JH. Incarcerated femoral hernia including a gangrenous appendix. J Korean Surg Soc 2007;72:430-2.