Amyands hernia in pediatric case: Manageable but challenging to diagnose preoperatively

Introduction

Inguinal hernia may contain rare entities such as ovary, fallopian tube, urinary bladder, large bowel diverticula or meckels diverticulum described as Littre.1 These rare content make hernia surgery a new challenge.

Presence of vermiform appendix within inguinal hernia sac with or without inflammation is termed as amyands hernia first described by cladius amyands in London in 11 years old boy and performed successful appendectomy.2, 3

Appendix in hernia sac content incidence varies from 0.5% to 1%, may become complicated by acute appendicitis in 0.8% to 0.13% as inflamed/uninflamed, stretched/curved, adhered/not adhered to sac wall.4, 5, 6 Here we report a case of amyands hernia in 2 year child without inflammation managed successfully by appendectomy and herniotomy.

Case Report

A 2 year male baby presented with right sided inguinal swelling since birth. On examination, the swelling was inguinoscrotal, reducible, painless. Laboratory findings revealed leucocytosis with lymphocytocis with no evidence of urinary tract infection. Ultrasonography of scrotum revealed right indirect inguinal hernia with no testis involvement and normal epididymis both sides. Intraoperative findings during herniotomy reveals presence of appendix approx 12 cm longc(Figure 1), ceacum as its contents with mild adhesions within. All adhesions were relieved and appendectomy was performed (Figure 2) with caecum reduced back to peritoneal cavity with closure of sac. Baby had smooth postoperative recovery, discharged without complications.

Figure 1

Intraoperative finding 12cm long appendix within hernia sac

Figure 2

Appendectomy followed by hernia sac closure.

Discussion

Amyands hernia was first described by Claudius in 1735. Losanoff and basson’s described the classifications with types.7, 8, 9, 10, 11, 12 Later Athena’s modification describes intraoperative findings.

Amyands hernia reduction alone or with appendectomy is described depending upon intraoperative findings. Appendectomy with herniotomy is preferred to reduce future complications that lead to appendicitis. Long appendix if spared May poses higher risk of inflammation due to stretching of caecum.

Mechanism of acute appendicitis within amynads hernia is due to decreased blood supply to appendix due to adhesions/compressions at external ring due to non reducibility leads to recurrent inflammation. Appendectomy helps structural reduction with anatomical repositions.

Appendicitis within amyands hernia is rare presentation due to incarceration from oedema at internal ring or contracted abdominal muscle at inguinal canal. 4, 5 Gold standard procedure in pediatric age group is herniotomy with appendectomy to minimize future reoccurrence as required in our patient. According to Athena’s modification our baby is in type 1 category, where we found appendix intraoperatively as contents accidentally. Appendectomy was done and content reduced which is considered standard treatment protocol. 7, 8, 9, 10, 11, 12

Initial USG radioimaging have cost effective approach towards sensitive evaluation with correlation of patients history but sometimes initial scans may be misleading as they misinterpret the contents and can only be confirmed during intraoperatively. Hence definitive preoperative diagnosis is challenging. Right sided amyands hernia occurrence is comparatively higher in incidence due to appendix anatomical location.

Conclusions

Clinical sign and symptoms in hernia presentations can be misleading regarding its content even during preoperative screening in USG where high sensitivity is promised. Surgeons during intraoperatively can land up into dilemma in cases such as amyands hernia where its content (appendix) may prevail accidentally. However findings may surprise surgeons but a systematic approach and standard intraoperative protocol always leads to good outcome.

Source of Funding

None.

Conflict of Interest

None.