Amyand's hernia: Our experience in the laparoscopic era.

Amyand's hernia is a rare presentation of inguinal hernia, in which the appendix is present within the hernia sac. This entity is a diagnostic challenge due to its rarity and vague clinical presentation. A laparoscopic approach can confirm the diagnosis as well as serve as a therapeutic tool. When the appendix is not inflamed within the inguinal hernia sac, then appendicectomy is not always necessary. Our case series emphasize the same presumption as three patient of Amyand's hernia underwent laparoscopic transabdominal preperitoneal hernioplasty without appendicectomy. The aim of this paper is to review the literature with regards to Amyand's hernia and provide new insight in its diagnosis and treatment.

INTRODUCTION

The term Amyand's hernia signifies presence of the appendix, either inflamed or normal, in the inguinal hernia. It is a rare entity. Incidence of occurrence of the normal appendix within inguinal hernia sac is 1% and that of an inflamed appendix is 0.1%.[1] It was first described by Claudius Amyand (1685-1740).[12]

Laparoscopic inguinal hernia repair has advantage of detection of type and nature hernia of the involved side as well inspection and repair of the opposite side in same setting. The status of the appendix in the hernia sac determines the type of hernia repair required. Usually, when appendix is normal then mesh hernioplasty is done for inguinal hernia. In the case of the inflamed appendix, anatomical hernia repair with appendicectomy is advised.[12]

We hereby report a case series of three patients of Amyand's hernia. We reviewed our hospital records of last 2 years and out of 179 operated patients for inguinal hernia, three were found to have Amyand's hernia. We performed mesh repair in all the three cases without appendicectomy as appendix was either normal or mildly congested.

CASE REPORTS

Case 1

A 46-year-old male patient presented with right inguinal hernia since 18 months. Clinical examination showed reducible indirect inguinal hernia, which was mildly tender. On palpation, abdomen was soft and non-tender. Laboratory investigations were within normal limit. As the surgery was elective and diagnosis of hernia is purely clinical, no ultrasound or computed tomography (CT) scan performed. Patient underwent laparoscopic transabdominal preperitoneal hernioplasty (TAPP). During surgery, appendix along with the omentum was found to be protruding into the inguinal canal through deep inguinal ring. After reduction, appendix looked congested and hypervascular. As there was no history of abdominal pain, we went ahead with usual hernioplasty using polypropylene mesh, without appendicectomy. Postoperative period was uneventful, and the patient was discharged on the next day of surgery. Patient was followed up for 18 months during which there was no episode of appendicitis.

Case 2

A young male, 28-year-old, was admitted as a case of right-sided inguinal hernia for elective hernia repair. Patient had inguinal swelling since childhood. Examination showed a complete, reducible and indirect hernia. There was no history of abdominal and vomiting. Laboratory parameters were within normal limit. Patient then underwent TAPP hernia repair. Hernia content was appendix, which was trapped inside the deep inguinal ring with adhesions all around [Figure 1]. Adhesions were released, and appendix was found to be grossly normal in appearance. Hence, in view of noninflamed appendix, preperitoneal mesh (polypropylene) hernioplasty was performed without appendicectomy [Figure 2]. After surgery, patient recovered well without any complications. Follow up period was 1 year that was uneventful.

Figure 1

Adhesions around deep inguinal ring with herniation of appendix

Figure 2

Mesh (Bard 3D) in pre-peritoneal space after dissection

Case 3

A 55-year-old male diabetic patient was admitted for elective right inguinal hernia repair. He had a history of right side reducible inguino-scrotal swelling since 3 years. Two weeks back before admission, he noticed that swelling was not fully reducible and slightly painful. Ultrasound of the abdomen reported normal findings. Other laboratory parameters were within normal limit. So, with a diagnosis of right sided partially reducible, incomplete and indirect inguinal hernia, patient was posted for laparoscopic TAPP hernia repair. Initial laparoscopy showed indirect hernia with caecum and omentum adherent to deep inguinal ring. Adhesions were released which revealed herniation of appendix into the inguinal canal. Appendix was mildly congested without gross evidence of inflammation. We proceeded with preperitoneal hernioplasty with polypropylene mesh. Postoperative recovery was uneventful. Patient was followed up for 10 months during which there was no attack of appendicitis or other complications.

DISCUSSSION

Claudius Amyand, surgeon to King George II of Britain, performed the first recorded appendectomy in 1735. The patient was an 11-year-old boy who had perforation of the appendix by a pin. In the early 1900s, this precedent was recognized and the condition was given the eponym Amyand's hernia.[12]

Amyand's hernia is three times more common in children than in adults, due to the patency of the processus vaginalis.[3] D'Alia et al. scrutinized 1341 inguinal hernias and reported that the incidence of Amyand's hernia was 0.6%, always occurs on the right side, and was found exclusively in males.[4] He also reported mortality of 14-30%, which was primarily due to peritonitis. The mortality can be minimized by early diagnosis and good perioperative care as reported by Sharma et al.[1] In our case series, incidence was 1.6% that is comparatively slight higher. This can be attributed to use of laparoscopy in hernia repair, which facilitate the detection of remote cases.

In our experience, the possible mechanism of appendicitis in Amyand's hernia is; appendix enters the sac, the deep ring compromises with the circulation and lumen of the appendix leading to a localized inflammatory process. This will lead to adhesions, which in turn further impede the blood supply and thereby causing appendicitis.

Definitive preoperative diagnosis poses a challenge due to indistinct clinical signs and symptoms. Incarcerated or inflamed appendix is often misdiagnosed as a strangulated hernia. Diagnosis of Amyand's hernia remains primarily an incidental finding during surgery.[1] CT scan can aid in making preoperative diagnosis of Amyand's hernia.[5]

Vermillion et al. reported the first instance of laparoscopic appendectomy for the treatment of Amyand's hernia with appendicitis.[5] Saggar et al. reported total extraperitoneal management, including appendectomy and hernioplasty using synthetic mesh.[6] Laparoscopic repair has also been described in pediatric age group.[78] Rehman et al. reported that laparoscopic surgery is feasible for Amyand's hernia repair even in an 8 weeks old infant.[8]

Milanchi et al. recommended mesh hernia repair without appendectomy, if the appendix is normal, and laparoscopic appendectomy, followed by open hernia repair in cases of appendicitis.[2] Hutchinson argued that appendectomy of a healthy appendix is not necessarily beneficial, and may actually be detrimental, as excision of a fecal-containing organ in an otherwise clean procedure may increase morbidity and mortality from septic complications.[9]

Losanoff et al. proposed a classification for management of Amyand's hernia.[10] They mentioned four types of hernia based on the condition of the appendix, along with treatment layout. Type I is a normal appendix in hernia sac; perform reduction with mesh hernioplasty, appendicectomy in young patients. Type II is acute appendicitis localized in the hernial sac; perform appendectomy through inguinal incision, no mesh hernia repair. Type III is acute appendicitis complicated by peritonitis; perform appendectomy through laparotomy, hernia repair without mesh. Type IV is acute appendicitis with or without abdominal pathology; manage as type I to III, treat abdominal pathology.

We performed mesh hernioplasty without appendicectomy in all. In our opinion, rectification of inguinal hernia should be the prime motive as appendicitis, if occurs, can be addressed later laparoscopically. Furthermore, inflammation can be because of entrapment of appendix in the inguinal canal, which will resolve once the hernia is reduced and repaired. Moreover, if mesh infection occurs after appendicectomy then it is a nightmare for a surgeon to treat it.

So to conclude, Amyand's hernia is primarily an incidental finding during surgery. There remains no true consensus on the best possible management approach. Laparoscopy for dealing Amyand's hernia is frequently diagnostic as well as therapeutic. The inflammatory grade of the appendix determines the surgical approach and the type of hernia repair. In our experience, whenever non or partially inflamed appendix is encountered, appendectomy should be avoided so that mesh hernioplasty can be performed.