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.