CASE 4474 Published on 05.02.2006

Amyand's hernia

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Cengizhan Yigitler (*), Giyasettin Basakinci(**), Kemal Kara(**), Emir Silit(*). Balikesir(*) and Van(**) Military Hospital's

Patient

20 years, male

Clinical History
Sonography performed patient complaining of pain and swelling in his right inguinal region, showed Amyand’s hernia
Imaging Findings
A patient was referred to the emergency room, complaining of pain and swelling in right inguinal region, and fever, lack of appetite, nausea and vomitting, that gradually increased last two days. His medical history revealed that he had an inguinal swelling that extends to scrotum, for two years. On physical examination, there were pain, tenderness and moderate rebound in his right lower quadrant and a painful, nonreducable, 3x5 cm mass located inferiorly to the external inguinal ring. Laboratory analysis showed mildly elevated white blood cell count. Sonography, performed to evaluate his irreductable mass, showed the dilated (9 mm diameter) thick walled appendix surrounded with fluid and omental structures, within inguinal hernia sac. At surgery, an inflamed appendix and edematous omental structures were seen in the dilated internal inguinal ring. Appendectomy, partial omentectomy and herniorhapy was performed. To avoid the increasing inflamatory response, prosthetic material did not used to repair of abdominal wall. The patient was discharged, without complication, at postoperative 5th day.
Discussion
Amyand’s hernia, firstly reported by the surgeon Claudius Amyand in 1735, is an acute appendicitis occuring within an inguinal hernia sac (1). A normal appendix in a hernia sac is estimated to be found in approximately 1% of inguinal hernia repairs. An appendicitis in the inguinal hernia is further rare, D’Alla reported 0,08 % whereas Ryan 0,13 % in their series (2). It’s clinical presentation varies and usually point out an incarcerated hernia, so it almost never been diagnosed preoperatively. Only one case has been reported, to be diagnosed correctly before the surgery, in 60 cases of Amyand’s hernia from 1959 to 1999 (3). Amyand’s hernia was firstly reported in imaging literature, by Luchs et al that they used the computed tomography (CT) to confirm an incarcerated inguinal hernia (4). The diagnostic accuracy of the CT is surely high to evaluate abdominal and pelvic abnormalities, but the routine use of CT doesn’t suggested for imaging patients with the clinical diagnosis of incarcerated hernia. To our knowledge, sonographically diagnosed Amyand’s hernia has not been reported before. In our case, surgically proven acute appendicitis in the hernia sac was demonstrated by sonography. The treatment of Amyand’s hernia includes appendectomy and primary hernia repair without using synthetic mesh, to avoid a wound infection and a possible appendiceal stump fistula (3). Acute appendicitis should be considered as a potential cause of increased morbidity in patients whose hernias are manually reduced under sedation or analgesia (5). On the contrary of CT, sonography which is useful modality for intraabdominal, pelvic and abdominal wall pathology, can be used routinely for detecting the contents of the henias. So the patient management and surgical approach can be planned that effects the patient’s outcome.
Differential Diagnosis List
Amyand's hernia
Final Diagnosis
Amyand's hernia
Case information
URL: https://www.eurorad.org/case/4474
DOI: 10.1594/EURORAD/CASE.4474
ISSN: 1563-4086