Teaching Case

59 years old male presented with sudden onset of severe right lower quadrant pain. Examination revealed a septic patient with generalized abdominal tenderness and an irreducible inguinal hernia on the right side.

This patient presented with acute onset of severe right lower quadrant pain radiating to his lower back. He had no bowel or urinary symptoms.

His past medical history was remarkable of right inguinal hernia for which he had refused surgery in the past. He had no previous history of abdominal surgery.

Examination revealed unwell patient with: BP 115/74, pulse rate 124/min, temperature 38.1 degree centigrade, respiratory rate 16/min. There was an irreducible right inguinal hernia associated with severe right lower abdominal tenderness and generalised guarding.

Initial Chest X-ray and Abdominal X-ray were unremarkable (AXR shown: figure 1). CT scan of the abdomen revealed a ruptured appendix associated with an abscess tracking down into the right scrotal sac through an inguinal hernia on the same side (figure 2).

Emergency laparotomy revealed purulent material in the abdominal cavity with a hernia sliding into the right inguinal canal, which contained caecum, appendix and terminal ileum. Reduction of sliding hernia, internal herniorrhaphy and appendicectomy were carried out. Postoperative period was complicated by septicaemia, ARDS and fast AF. Initial attempts to extubate failed, thus ITU stay was prolonged.

Persistent signs of septicaemia in spite of broad spectrum antibiotics prompted a second CT scan, which revealed fluid filled collections in different areas of the abdomen and bilateral pleural effusions. Following this he underwent two further laprotomies and washouts. He remained stable afterwards and continued to improve. He was subsequently discharged home on 18th day after admission.

Acute appendicitis in an incarcerated inguinal hernia is termed as Amyand's hernia. It is uncommon and is approximately 1% of adult inguinal hernia repairs, and when it occurs it is often misdiagnosed as a strangulated inguinal hernia. Claudius Amyand performed the first recorded successful appendectomy on an 11-year old boy with a perforated appendix within an inguinal hernia sac in 1735. [1]

Amyand hernia is rare, and its proper diagnosis can be ascertained only with high clinical suspicion, since the symptoms associated with this disease state vary considerably, depending on the presence of intraperitoneal contamination. The most common clinical presentation involves rapidly progressive tenderness over a previous external hernia site, suggestive of a strangulation or incarceration in the absence of radiographic evidence of obstruction. [2] Our patient presented with similar clinical picture.

The age group for this condition ranges between 6 weeks and 88 years, and only a slight male predominance has been observed. Most female patients with hernial appendicitis are postmenopausal and are found to have true femoral hernias. [2]

In a report of 10 cases of hernial appendicitis by Carey, [3] none were correctly diagnosed preoperatively, and x-ray films afforded little or no help even when coupled with significant clinical findings. The differential diagnosis for this condition includes incarcerated or strangulated inguinal hernia, inguinal lymphadenitis, testicular torsion, acute epididymitis, acute hydrocoele, and focal panniculitis. [3, 4]

The correct preoperative diagnosis is difficult and requires an awareness of this entity. We point out that although Amyand's hernia is a very rare clinical entity, it should always be considered in the differential diagnosis in cases with clinical signs of incarcerated right inguinal hernia, especially when there are no pathological findings on the abdominal X-rays.

Leukocytosis and fever are not consistent findings. Preoperative computed tomography (CT) revealed the previously unsuspected diagnosis of Amyand’s hernia in some reports [5]. However, CT is not routinely used.

The treatment for hernial appendicitis includes appendectomy with hernia repair. Laprotomy is indicated in the presence of diffused peritonitis.