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American Board of Abdominal Surgery


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ADOMINAL SURGERY

Official Journal of the American Society of Abdominal Surgeons, Inc.

This article originally appeared in the Winter 20012 / Spring 2013 issue of the Journal.

Amyand's Hernia With Reactive Lymphoid Hyperplasia of the Appendix Treated with Appendectomy & Mesh Implantation

Jonas P. DeMuro, M.D., F.A.C.S.
Attending Surgeon and Intensivist
Winthrop University Hospital

Address for correspondence:
Jonas P. DeMuro, M.D., F.A.C.S.
Winthrop University Hospital
Department of Surgery
Division of Trauma and Critical Care
259 First Street
Mineola, NY 11501
Tel: (516) 663-8700
Fax: (516) 663-8707
E-mail: jdemuro@winthrop.org


ABSTRACT

Amyand’s hernia describes the rare hernia of the appendix within the inguinal sac. A case of an Amyand’s hernia with the appendix diagnosed as reactive lymphoid hyperplasia on pathology is presented. The surgical care of this patient is discussed, reviewing the successful implantation of mesh in the inguinal hernia repair with a simultaneous appendectomy.

Keywords: hernia, appendix, inguinal, lymphoid hyperplasia

INTRODUCTION

The i nguinal hernia, with occasional incarcera tion and obstruction, is a common surgical problem. The organs incarcerated in the hernia sac include small bowel, large bowel, urinary bladder, bladder diverticula, ovary, fallopian tub e, and less commonly a Meckel’s diverticulum (Littre’s hernia) , and unusually, the appendix . When an appendix is loca ted in an ing uinal herni a sac , this is known as an Amyand’s hernia, named after Cla udiu s Amyand, King G eor ge II’s surgeon. He was the f irst surgeon to perform an appen dectomy in 1 735, in a child that had perf orate d appendicitis within an incarcerated hernia.1 While the appendix in the hernia sac can be normal or with appendicitis to be considered an Amyand hernia, there is no previously reported case of an Amyand’s hernia with reactive lymphoid

CASE PRESENTATION

Figure 1

click to enlarge

A 47 year old male presented to the Emergency Department after a 2 day history of nausea, vomiting, obstipation, constipation and abdominal pain. His admission laboratories were significant for a white blood cell count of 12.1 K/µL with a left shift and normal chemistries. On examination, he had evidence of an acutely incarcerated right inguinal hernia, with skin changes, that was unable to be reduced. (Figure 1)

With no need for further imaging, the patient was brought emergently to surgery and induced under general anesthesia. Through an inguinal incision, the incarcerated appendix and cecum were identified in the inguinal canal through a direct defect. The internal inguinal ring had to be incised and enlarged to allow for a manual reduction of the contents. The cecum appeared to have venous congestion, and the appendix appeared abnormally dilated, but without gross evidence of acute appendicitis. The decision was made to perform an appendectomy due to the abnormal appearance, which was done with a single load of a 45 mm GIA stapler. As there was no gross contamination, the direct defect was closed with a marlex plug and patch technique.

The patient was discharged the next day, and he made a full recovery with no recurrence of his hernia on short term followup. The final pathologic diagnosis on the appendix was reactive lymphoid hyperplasia with evidence of enlargement to 1 cm.

DISCUSSION

Amyand’s hernia is defined as the presence of an appendix within the inguinal hernia sac. It usually occurs on the right side,2 with an incidence estimated to be 1% of adult inguinal hernias.3 As in the case presented, the diagnosis of Amyand’s hernia is most commonly made intraoperatively to avoid a delay in repairing an incarcerated hernia, but CT with oral contrast, abdominal X-rays, and scrotal ultrasound have been reported to be useful for preoperative diagnosis in less emergent cases.4

It remains controversial in Amyand’s hernia whether to perform a simultaneous appendectomy.5,6 It is generally advocated that if the appendix is normal it should be preserved, and the inguinal hernia repair should be done with a prosthetic mesh, and in cases of an Amyand hernia with acute appendicitis, it should be handled with an appendectomy, and a primary inguinal hernia repair without prosthetic mesh.7

This is the first case reported in the literature of an Amyand’s hernia with the appendiceal pathology showing reactive lymphoid hyperplasia, suggesting an underlying viral illness.8 With the identification of an abnormal appendix, appendectomy should proceed via a transinguinal approach, preferably with a stapled technique to minimize the contamination. This experience adds to the handful of cases reported with prosthetic mesh utilized in an Amyand’s hernia with an appendectomy,9 which is superior to prevent recurrence of the hernia compared to primary repairs without mesh.10

REFERENCES

1. Anagnostopoulou S, Dimitroulis D, Troupis TG, et al.Amyand’s hernia: A case report. World J Gastroenterol.2006;12:4761-4763.

2. Kwok CM, Su CH, Kwang WK, Chiu YC. Amyand’s Hernia- Case Report and Review of the Literature. Case Reportsin Gastroenterology. 2007;1:65-70.

3. Thomas WEG, Vowles KDJ, Williamson RCN. Appendicitis inexternal hernia. Ann R Coll Surg Engl. 1982;64:121-122.

4. Muslu U, Cetinkaya OA. Amyand’s Hernia: Report ofTwo Cases and a Review of the Literature. Kolon RektumHast Derg. 2011;21:130-135.

5. Psarras K, Lalountas M, Baltatzis M et al. Amyand’shernia- a vermiform appendix presenting in an inguinalhernia: a case series. Journal of Medical Case Reports.2011;5:463.

6. Hutchinson R. Amyand’s hernia. Journal of the RoyalSociety of Medicine. 1993;86:104-105.

7. Telkar S, Goudar BV, Lamani YP, Ambi U. Non-slidingAppendiceal Hernia (Amyand’s Hernia): A Case Report.Journal of Clinical and Diagnostic Research.2011;5:1289-1290.

8. Rabah R. Pathology of the appendix in children: an institutionalexperience and review of the literature. PediatrRadiol. 2007;37:15-20.

9. Singal R, Gupta S. Amyand’s Hernia- Pathophysiology,Role of Investigations and Treatment. MÆdica – aJournal of Clinical Medicine. 2011;6:321-327.

10. Kulacoglu H. Current options in inguinal hernia repair inadult patients. Hippokratia. 2011;15:223-31.



Journal CoverOFFICIAL PUBLICATION OF:
The American Board of Abdominal Surgery
The American Society of Abdominal Surgeons, Inc.
Foundation for Abdominal Surgery

Louis F. Alfano, Jr., M.D., Editor-in-Chief
Diane M. Pothier, Executive Editor and
Director of Continuing Medical Education


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Figure 1: Left Lobe Hydatid