Ibrahim I Jabbour, MD, MPH, Samuel E Kirkendall, MD, Shohan Shetty, MD, Nancy Puzziferri, MD. UT Southwestern Medical Center (Dallas, TX)
Amyand’s hernia is an extremely rare condition in which the appendix is found in the inguinal hernia sac. The first report of Amyand’s hernia in 1735, was described in an 11-year-old boy with concurrent ruptured appendicitis. Since that time less than two hundred cases of Amyand’s hernia have been reported in the literature. In adults, the overall incidence of a normal appendix in the hernia sac is approximately 1%, whereas appendicitis in the hernia sac is approximately 0.1%. We report a case of Amyand's hernia with perforated appendicitis found in a 60-year-old male, which was repaired using biological mesh.
A 60-year-old male with no pertinent past medical or surgical history presented with three days of worsening right groin pain and swelling. The swelling in the right groin was tender and without skin changes. Computed tomography of the abdomen showed an inflamed appendix incarcerated into the right inguinal canal with likely perforation. Initially a diagnostic laparoscopy was performed which revealed an incarcerated appendix that could not be reduced into the peritoneal cavity. An open right inguinal hernia repair was subsequently performed in the Lichtenstein fashion using Strattice Reconstructive Tissue Matrix (Lifecell, Branchburg, NJ). Postoperatively the patient had minimal cellulitis at the surgical site. He improved with intravenous antibiotic therapy and had an uneventful postoperative course. At short-term follow-up there were no signs of infection or hernia recurrence.
Classically, acute appendicitis is thought to be caused by luminal obstruction. However, in Amyand's hernia with appendicitis there are two proposed mechanisms. Inflammation of the appendix may lead to edema in the internal ring and subsequent incarceration and obstruction of the appendix. Another etiology may start with the contraction of abdominal muscles in the inguinal canal leading to incarceration of a normal appendix. This ultimately leads to ischemia and the inflammatory cascade with bacterial overgrowth. Peritonitis is unlikely to occur because the hernia sac acts as a barrier to the purulent material.
Inguinal hernia repairs with mesh have been shown to have a decreased recurrence compared to primary tissue repair. Synthetic mesh is generally avoided in an infected or contaminated field. Some surgeons however, advocate synthetic mesh repair after thorough intraoperative irrigation and perioperative antibiotics. We preferred to use a biological mesh in the contaminated field to avoid postoperative infection and hernia recurrence, though clinical trials are lacking in this area.
Amyand’s hernia with ruptured appendicitis is a rare clinical entity. We report a case of a perforated appendix within a right inguinal hernia, which was repaired using biological mesh in a contaminated field with no sign of infection or recurrence at short-term follow-up.