Amyand's hernia.

We report two children with Amyand's hernia, where the appendices along with caecum were found within the left hernial sac, which were operated for obstructed inguinal hernia.

INTRODUCTION

The incidental finding of the vermiform appendix lying within an inguinal hernia occurs in approximately 1% of the cases of inguinal hernia, and is known as an Amyand's hernia.[1-3] We present two such cases of Amyand's hernia discovered incidentally at surgery for left-sided obstructed inguinal hernia and briefly review the literature on the topic.

CASE REPORTS

Case 1

A 1.5 years old male child came with complaints of swelling of the left scrotal region since birth, which was earlier reducible and had become irreducible 2 days prior to admission. There was also history of bilious vomiting and fever for 1 day. Clinical examination revealed a tender, irreducible swelling in the left inguinal region and diagnosis of obstructed left inguinal hernia was made. Intravenous fluids and antibiotics were started and the child was prepared for surgery.

At surgery, on opening the hernial sac, the appendix and the caecum were found to be lying within along with caecal perforation. The appendix was not inflamed. The caecal perforation was closed and reduced within the abdominal cavity. Peritoneal toileting was not performed as perforation was localized in the scrotal region. No appendectomy was carried out. Herniotomy was performed. He had an uneventful postoperative stay. Postoperatively, radiographs of the chest and abdomen and ultrasonography of the abdomen were performed to rule out situs inversus. It was confirmed that the cause of the left-sided Amyand's hernia was mobile caecum.

Case 2

A 1.5 years old male child presented to us with left irreducible scrotal swelling. On examination, the local temperature was raised and tenderness was present along with redness of the overlying skin. It was diagnosed as a case of obstructed left inguinal hernia. He was started on intravenous antibiotics and was prepared for surgery. Ultrasound showed dilated aperistaltic small bowel loop herniating through the left inguinal canal into the scrotum. Diagnosis of strangulated left inguinal hernia was made.

At surgery, the appendix along with caecum and the distal ileum were found to be lying within the hernial sac. The appendix was healthy but the caecum was edamatous and inflammed. There was serosal tear of ileum near the ileocaecal junction, which probably occurred during pulling of the loop from the scrotal sac. No appendectomy was performed and serosal tear of the ileum near the ileocaecal junction was repaired and reduced to abdominal cavity. Herniotomy was performed. He had an uneventful postoperative stay.

DISCUSSION

Amyand's hernia is extremely rare in children, especially in infants and neonates.[4-7] Till date, less than 20 cases have been reported in the English literature.[8]

Most of the cases occur on the right side, probably as a consequence of the normal anatomical position of the appendix and also because right-sided inguinal hernias are more common than left-sided hernias.[9] Although Amyand's hernia has also been reported on the left side, this is rare and may be associated with situs inversus, intestinal malrotation or a mobile cecum.[10-14]

The majority of the reported cases present with the features of an obstructed or strangulated inguinal hernia or with or without features of appendicitis.[571516] The diagnosis is made intraoperatively as the patient undergoes surgical exploration for a complicated inguinal hernia as in the present case where appendix was incidentally found in the hernial sac. A preoperative ultrasonography[17] and computed tomography scanning of the abdomen could be helpful for diagnosis, but this is not a routine practice after the clinical suspicion of a complicated inguinal hernia.[4] However, one case of a 3-month-old boy has been reported in which a right-sided sliding appendiceal inguinal hernia was diagnosed preoperatively with sonography.[17]

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 performed. The majority of the authors agree that a normal appendix within the hernial 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.[18] However, some suggest that in case of left-sided Amyand's hernia, appendectomy is performed even if appendix is normal to prevent any atypical clinical presentation of appendicitis in the future because, in these cases, the caecum is mobile or the patient has situs inversus or intestinal malrotation.[10] In our two cases, appendectomy was not carried out as in one case caecum was perforated and in another it was inflamed and edematous.