Issue Year : 2007, Issue Number : 2, Issue Month : June
Written By : Jan Muhammad Memon, Syed Qaiser Hussain Naqvi, Syed Qarib Abbas Shah, Saeeda Memon, Mohan. K. Khatri
A RARE VARIATION OF AMYAND’S HERNIA
Article
ntroduction
An inguinal hernia in which appendix is involved, is termed as “Amyand’s hernia”. Claudius Amyand first described in 1735, the presence of the vermiform appendix within an inguinal hernial sac has carried this name [1]. The incidence of normal appendix with an inguinal hernia sac is estimated to be approximately 1% of all cases of inguinal hernia, where as acute appendicitis presenting in an inguinal hernia is an uncommon event as 0.1% of all cases of hernial appendicitis [2] and a case of incarcerated appendix within an hernial sac was reported in the literature [3] and is referred as hernial appendicitis 16 years ago [4].
Here we report an incidental finding during emergency inguinal hernial swelling exploration where appendix was found in the hernial sac. To the best of our knowledge regarding this unusual variation of Amyand’s hernia very few cases are reported. The presented case points to the necessity of considering acute appendicitis in differential diagnosis of incarcerated right inguinal hernia.
Fig. 1:     Appendix herniating independently through the hernial sac.
Fig. 2:     Appendectomy through hernial sac.
Case Report

Correspondence: Dr Jan Muhammad Memon, Assistant Professor of Surgery, Peoples Medical College, Nawabshah (Sindh).

A 50-years old otherwise healthy male presented for the evaluation of right inguinal bulge and slight discomfort in the department of surgery, Peoples Medical College Hospital Nawabshah through emergency department. He was a farmer and heavy weight lifter and smoker also. The presenting complaints were irreducible right inguinal bulging with discomfort, low grade fever and nausea. Physical examination revealed right inguinal swelling of about 6x9 cm favoring irreducible right inguinal hernia. Emergency surgical exploration made under spinal anesthesia. Right inguinal incision was made over the bulge. The operative findings revealed indirect right inguinal hernia with grossly inflamed appendix herniating independently through the hernial sac (fig. 1). There was naked eye evidence of acute appendicitis so appendectomy through hernial sac (fig. 2) and herniotomy with darn herniorrhaphy (fig. 3) were performed at the same time. The postoperative course was uncomplicated and patient remained afebrile. He resumed oral intake on 1st postoperative day after resumption of early bowel activity and discharged on 2nd postoperative day. The histopathological examination revealed acute appendicitis. At one year follow-up there was no recurrence of hernia.

Discussion

A
The explanation of this unusual anatomical variation of Amyand’s hernia is that of a subcaecal variety of appendix herniating through the inguinal canal along with the hernial sac. The exaggerated descent of caecum towards the right iliac fossa may bring the subcaecal appendix in close proximity to the internal inguinal ring and may favor the sliding of the appendix independently into the inguinal canal on the occasion of concurrent adjacent and femoral henial sac.

Amyand’s hernia with the finding of vermiform appendix in the inguinal hernial sac is a rare entity, while acute appendicitis associated with an Amyand’s hernia is extremely a rare variety being 0.13% [5]. After a review of literature, very few cases are reported in the literature up to date [6-11]. Amyand’s hernia should be differentiated from Litter’s hernia [12], Richter’s hernia [13], Maydl’s hernia [14], inguinal lymphadenitis, acute epididymitis, testicular torsion and focal paniculitis. The diagnosis of the Amyand’s hernia is usually made intraoperatively. The prospective diagnosis of this condition is possible however a preoperative C.T scan of the abdomen is obtained.
Philip in 1967 [15] reported 15 cases of right inguinal hernia with afferent loop obstruction and with freely mobile appendix that can convert into Amyand’s in cases of appendicitis. Qazi Jalal-uddin [16] reported single case study of Amyand’s hernia in Pakistan with inflamed appendix, appendectomy, herniotomy and Bassini’s herniorrhaphy performed at the same time.
The review literature affirms that management of Amyand’s hernia depends on intra-operative findings like the presence of normal appendix in an inguinal hernial sac does not require appendectomy while inflamed appendix should be treated by appendectomy via hernial sac and also the herniotomy and herniorrhaphy should be performed in the same session.
Reference
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