CASE REPORT


https://doi.org/10.5005/jp-journals-10082-03174
SBV Journal of Basic, Clinical and Applied Health Science
Volume 6 | Issue 1 | Year 2023

A Rare Herniation of Obstructed Amyand


Maruduraj VC1https://orcid.org/0000-0002-9758-8247, Muralidharan Gopalan2, Eshwar Karthikeyan K3https://orcid.org/0000-0002-0403-9071, Fazil Navidh4, Sharan Bhooshan5, Mohana Priya6

1Department of Surgery, Razack Hospital, Thoothukudi, Tamil Nadu, India

2–6Department of General Surgery, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed to be University), Chennai, Tamil Nadu, India

Corresponding Author: Maruduraj VC, Department of Surgery, Razack Hospital, Thoothukudi, Tamil Nadu, India, Phone: +91 9944512360, e-mail: marudhurajcool@gmail.com

How to cite this article: Maruduraj VC, Gopalan M, Karthikeyan EK, Navidh F, Bhooshan S, Priya M. A Rare Herniation of Obstructed Amyand. J Basic Clin Appl Health Sci 2023;6(1):9–11.

Source of support: Nil

Conflict of interest: None

Received on: 05 September 2022; Accepted on: 31 October 2022; Published on: 31 December 2022

ABSTRACT

Aim: To report a rare case of strangulated inguinal hernia with appendix and cecum as content.

Case description: A 32-year-old male came to the emergency department with severe pain in the right inguinal region. The patient was examined and diagnosed clinically with obstructed inguinal hernia. The patient was prepared for emergency exploration and intraoperative findings were strangulated inguinal hernia with cecum as an appendix as content. A laparotomy was done and the strangulation was relieved followed by an appendicectomy. The postoperative period was uneventful.

Conclusion: With the incidence of strangulation in bowel contents in the inguinal region kept increasing, immediate resuscitation and exploration with laparotomy are inevitable to avoid drastic complications.

Clinical significance: With the incidence of strangulated inguinal hernia with cecum and appendix as content, a high index of clinical suspicion is of utmost importance in identifying and correctly managing this rare condition.

Keywords: Amyand, Appendix, Laparotomy, Obstruction.

INTRODUCTION

Inguinal hernias hold the status of one of the most incidental surgical importance. By definition, the hernia is a protrusion, bulge, or projection of an organ or a part of an organ through the body wall that normally contains it. Hernia happening in the inguinal region is an inguinal hernia. Out of all kinds of abdominal wall hernia, the inguinal hernia has the most part of the incidence rate of about 75%. In an inguinal hernia,1 two specific types – direct and indirect – are as differentiated by the anatomical position. Congenital incidence of inguinal hernia treated as early as possible. Acquired incidence of inguinal hernia is usually due to the increased abdominal pressure so that the contents protrude through the weakened parts. In the case of indirect hernia, there is a chance of obstruction of the neck of the content, and the vascularity may get compromised leading to gangrenous contents and life-threatening complications.2 In this case, we are going to report on one such kind of rare scenario in which the appendix gets obstructed and discussion about the indication of emergency exploration.

CASE DESCRIPTION

A 35-year-old old male who is a truck driver by occupation with complaints of swelling over the right groin (Fig. 1) which did not reduce and is associated with severe pain from the morning. The patient noticed swelling over the right groin 7 years back which was sudden in onset, aggravated on work, and relieved on lying down which was initially smaller in size and gradually developed to the present size; from the morning, the patient could not reduce the swelling manually and is associated with pain. The history of (H/o) pain from the morning which was sudden in onset after defecation, pricking type, continuous, and aggravated with movements without any relieving factors. There is history present vomiting from the morning right after food intake, food contents, two episodes, food contents, non-bilious, non-foul smelling. The H/o heavyweight lifting present. No H/o similar episodes in the past. No H/o any known comorbid conditions. No H/o surgeries in the past. On clinical examination, the patient was in tachycardia, and on abdominal examination, it was found a swelling of size 5 cm (Fig. 2) in diameter over the right inguinal region, extending from 5 cm from the pubis superiorly and laterally to the root of the penis that was ovoid shaped; skin was stretched and shiny. The surface appears to be smooth. The hernial orifice appears to be free on the left side. Painful cough impulse along with prominent veins. Swelling gets prominent on head raising. On palpation, swelling of size 5 cm in diameter over the right inguinal region, extending from 5 cm from the pubic tubercle superiorly and laterally to the root of the penis. Tenderness was present over the right inguinal region. The swelling was irreducible. The patient was assessed for immediate surgical intervention.

Fig 1: Swelling in right inguinal region

Fig. 2: Tender inguinal region swelling

Intraoperative Findings

  • Cecum and appendix identified as content (Figs 3 and 4).

  • Mild ischemic changes were seen over the cecum (Fig. 3).

  • Ischemic appendix.

  • Contents could not be reduced (Figs 4 and 5).

Fig. 3: Ischemic content in the sac

Fig. 4: Ischemic appendix

Fig. 5: Healthy ileocecal junction

A midline incision was made and deepened; the peritoneum was opened. The contents were reduced through the midline incision. A warm saline wash was given. After warm saline packing, strangulated bowel loops in which the appendix was found to be unhealthy. A thorough wash with warm saline was given.

Posterior wall strengthening was done; hemostasis was secured. An abdominal drain and a suction drain were placed. The external oblique aponeurosis (EOA), subcutaneous layer, and skin were closed in layers. Linea alba closed with 1/0 Loop Ethilon in a continuous interlocking fashion. The skin was closed with 2/0 Loop Ethilon and a sterile dressing was done.

DISCUSSION

As per the anatomical location of the protrusion of abdominal contents, the groin hernia is classified into an inguinal and femoral hernia.3 Inguinal hernia is further classified into direct and indirect hernia. A direct hernia occurs medially to the inferior epigastric vessels (in the Hesselbach’s triangle) and the indirect hernia occurs laterally to the vessel through the inguinal canal from the deep ring and the superficial ring. Inguinal hernia is also classified as reducible and non-reducible as per the content-reducing ability (Table 1). The non-reducible content high likely prone to get obstructed in the deep ring and converted to obstruction and strangulation as follows. In an obstructed inguinal hernia, the lumen of the bowel or the contents gets obstructed. In contrast way, with the strangulated hernia along with the luminal obstruction, there is also vascular compromise leading to the ischemia of the bowel, and gangrenous complications.4 Indirect inguinal hernias have a higher risk of strangulation. The risk of strangulation and obstruction is lowest for direct inguinal hernias as they have a wide neck, in which the contents can get reduced themselves and can often be monitored. Strangulated external hernias account for 18–20% of all intestinal obstructions in adults.5 Indirect inguinal hernias carry more risk of strangulation and incarceration than direct hernias. Herniation of the abdominal wall in which urinary bladder as content accounts for 1–3% of all inguinal hernias. It is frequently unilateral, on the right side with a 70% male predominance. Other risk factors include older age, obesity, and a H/o herniorrhaphy (recurrence). In the case of recurrent urinary tract infection and pelvic straining in case of benign prostate enlargement, there are high chances of weakening of the abdominal wall muscle and eventually ending up as the abdominal wall hernia, especially in the inguinal region.

Table 1: Inguinal hernia classification − Nyhus classification, 1993
Type I Indirect inguinal hernia with a normal ring sac in the canal
Type II Indirect hernia with an enlarged internal ring but the posterior wall is intact; inferior deep epigastric vessels not displaced, sac not in scrotum
Type IIIa Direct hernia with a posterior floor defect only
Type IIIb Indirect hernia with enlargement of internal ring and posterior floor defect
Type IIIc Femoral hernia
Type IV Recurrent hernia
  A direct Β indirect C femoral
  D combinations of A−B−C

In case of obstruction, the patient was presenting to operation with severe pain over the inguinal region. The patient was assessed and taken up for surgery immediately. Sac was opened and the contents were visualized and looked out for vascularity and bowel stability. If the contents were found to be ischemic or unhealthy, reduced the content by releasing the ring obstruction and look out for the ischemic changes to be undergone back to color change. If the ischemic changes not getting relieved followed by warm saline and 100% oxygen supply,6 depending on the level of obstruction, the resection was done under sterile conditions. In our case, the obstruction is at the level of the ileocecal junction with obstructed appendix (Table 2), the obstruction relieved and appendicectomy was done to rule out the possibility of future complications.

Table 2: Rikki’s classification of Amyand hernia
Classification Description Surgical management
Type I Normal appendix within an inguinal hernia Hernia reduction, mesh repair, appendicectomy in young patients
Type II Acute appendicitis within an inguinal hernia, no abdominal sepsis Appendicectomy through hernia, primary repair of hernia, and no mesh
Type III Acute appendicitis within an inguinal hernia, abdominal wall, or peritoneal sepsis Laparotomy, appendicectomy, primary repair of hernia, and no mesh
Type IV Acute appendicitis within an inguinal hernia, related or unrelated abdominal pathology Manage as types I to III hernia, investigate or treat second pathology as appropriate
Type Va Normal appendix within an incisional hernia Appendicectomy through hernia, primary repair of hernia including mesh
Type Vb Acute appendicitis within an incisional hernia, no abdominal sepsis Appendicectomy through hernia, primary repair of hernia
Type Vc Acute appendicitis within an incisional hernia, abdominal wall, or peritoneal sepsis or in relation to previous surgery Mange as type IV

CONCLUSION

Obstructed Amyand hernia is a clinically rare entity that is very hard to diagnose preoperatively. Intraoperatively, if the appendix is found to be the content of the hernia sac, chances of complications are higher and proved to be fatal at times. Radiological imaging also proved to helpful modality. Treatment involves appendicectomy in inflamed appendix through the herniotomy incision itself with meticulous hernia repair or in need of laparotomy in case of extensive repair.

ORCID

Maruduraj VC https://orcid.org/0000-0002-9758-8247

Eshwar Karthikeyan K https://orcid.org/0000-0002-0403-9071

REFERENCES

1. Sharma H, Gupta A, Shekhawat NS, Memon B, Memon MA. Amyand’s hernia: A report of 18 consecutive patients over a 15-year period. Hernia 2007;11(1):31–35. DOI: 10.1007/s10029-006-0153-8.

2. Constantine S. Review of literature: Computed tomography appearances of Amyand Hernia. J Comput Assist Tomogr 2009;33(3):359–362. DOI: 10.1097/RCT.0b013e3181837fd9.

3. D’Alia C, Lo Schiavo MG, Tonante A, Taranto F, Gagliano E, Bonanno L, et al. Amyand’s hernia: Case report and review of the literature. Hernia 2003;7(2):89–91. DOI: 10.1007/s10029-002-0098-5.

4. Komorowski AL, Rodriguez JM. Amyand’s hernia: Historical perspective and current considerations. Acta Chir Belg 2009;109(4):563–564. DOI: 10.1080/00015458.2009.11680487.

5. Milanchi S, Allins AD. Amyand’s hernia: History, imaging, and management. Hernia 2007;12(3):321–322. DOI: 10.1007/s10029-007-0304-6.

6. Gupta S, Sharma R, Kaushik R. Left-sided Amyand’s hernia. Singapore Med J 2005;46(8):424–425. PMID: 16049614.

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