Abstract
A
With the suspicion of incarcerated relapsed inguinal hernia, emergency surgery was performed. After hernia sac opening, we checked its contents, which corresponded to an evolved appendicitis with free purulent liquid (Fig. 1). Appendectomy and thorough lavage was carried out followed by a Shouldice's herniorraphy. Pathologic study confirmed the lesion was gangrenous appendicitis. Ertapenem was administered intravenously during his hospital stay, 1 g/24 h. The post-operative period was uneventful, and the patient was discharged home on day 4 with amoxicillin–clavulanic acid, 875 mg/125 mg q 8 h orally for 5 days.
Right inguinal oblique incision. Evolved appendicitis protruding through a right inguinal recurrent hernia. Vermiform appendix (A). Spermatic cord (B).
Amyand's hernia is the vermiform appendix protruding through an inguinal hernia, regardless its degree of inflammation. It represents 1% of all inguinal hernias, although its frequency seems to be even lower (0.4%–0.6%) [1]. The appendix also can be discovered inside a femoral hernia sac, what is named a De Garengeot hernia [2]. Clinical presentation of Amyand's hernia does not differ from that of an incarcerated inguinal hernia, which makes it difficult to determine whether the vermiform appendix is present along the hernia sac. Because of that, the diagnosis usually is achieved intraoperatively. Patients may present with pain and tenderness in the right lower quadrant, as well as with fever and vomiting. Blood analysis may show elevation of the white cell blood count and C-reactive protein. Ultrasonography and computed tomography may depict a tubular structure arising from the cecum, which helps to clarify the diagnosis.
There is a debate about the optimal treatment for this entity. The management depends on the Losanoff-Basson classification: Type 1 refers to a normal appendix, type 2 implies acute early-staged appendicitis, type 3 means perforated appendix or peritonitis, and type 4 represents the association between an inflamed appendix and another abdominal lesion [3]. Most authors agree that appendectomy should not be performed when the vermiform appendix is incidentally found and has no signs of inflammation, as this would add an unnecessary risk to the surgical procedure. Consequently, appendectomy should be reserved for types 2 to 4 according to the Losanoff-Basson classification [4].
The frequency of Amyand's hernia, in which the vermiform appendix protrudes through an inguinal hernia, is low. Its presentation as an incarcerated hernia becoming a surgical emergency is uncommon, and even rarer is its appearance within a recurrent inguinal hernia. Although some cases of incarcerated recurrent Amyand's hernia have been reported in the literature, such as the one in our patient, this finding represents an exceedingly uncommon presentation of this infrequent pathology [5].