Anatomic and Surgical Considerations in Amyand's Hernia

Anatomic and Surgical Considerations in Amyand's Hernia Anatomic and Surgical Considerations in Amyand's Hernia

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Hosp Aeronáut Cent 2012; 7(1): 14-15. Anatomic and Surgical Considerations in Amyand’s Hernia My. (E. Med.) Rubén D. Algieri (MAAC)*, María Soledad Ferrante (MAAC)**, 1er Ten. “e.c.” (E. Med.) Benjamín Nowydwor***, 1er Ten. “e.c.” (E. Med.) Verónica D´Amore***, 1er Ten. “e.c.” (E. Med.) Félix Viglione***, 1er Ten. “e.c.” (E. Med.) Alejandro Ciano*** General Surgery Service - Hospital Aeronáutico Central – Ventura de la Vega 3697 – Ciudad Autónoma de Buenos Aires (C.A.B.A.) * Head of the General Surgery Service, Hospital Aeronáutico Central. ** Surgeon of the General Surgery Service, Hospital Aeronáutico Central. *** General Surgery Resident, Hospital Aeronáutico Central. Received: January 18 th , 2012. Accepted: February, 15 th , 2012. Introduction Amyand’s hernia is characterized by the presence of the cecal appendix as content of the inguinal hernia, and it has low frequency (0.13% of the cases)(7,8,10,11). It usually presents as a complicated inguinal hernia. The acute appendicitis diagnosis is generally obtained during the intraoperative period. It has been named after Claudio Amyand (surgeon of King George II), who was the first to describe the presence of a perforated appendix related to a fistula within the inguinal hernial sac of an eleven-year-old child of approximately 4x4 cm., is irreducible and grows in size with the Valsalva maneuver. An urgency surgical conduct is decided (photos 1 and 2), with presumptive diagnosis of obstructed inguinal hernia. In the surgery, acute intraherniary appendicitis is identified. An appendectomy and anatomical inguinal hernioplasty are carried out. The patient evolves favorably during the postoperative period. (1,5). Objectives Case presentation and literature reviewed. Case Report 38-year-old, male patient who consults about a painful tumor in the right inguinal region, and 4- hours evolution sickness and vomits. The tumor, Photo 1. Intraherniary cecal appendix. 14

Hosp Aeronáut Cent 2012; 7(1): 14-15.<br />

<strong>Anatomic</strong> <strong>and</strong> <strong>Surgical</strong> <strong>Considerations</strong> <strong>in</strong> Amy<strong>and</strong>’s <strong>Hernia</strong><br />

My. (E. Med.) Rubén D. Algieri (MAAC)*, María Soledad Ferrante (MAAC)**, 1er Ten. “e.c.” (E. Med.)<br />

Benjamín Nowydwor***, 1er Ten. “e.c.” (E. Med.) Verónica D´Amore***, 1er Ten. “e.c.” (E. Med.) Félix<br />

Viglione***, 1er Ten. “e.c.” (E. Med.) Alej<strong>and</strong>ro Ciano***<br />

General Surgery Service - Hospital Aeronáutico Central – Ventura de la Vega 3697 – Ciudad<br />

Autónoma de Buenos Aires (C.A.B.A.)<br />

* Head of the General Surgery Service, Hospital Aeronáutico Central.<br />

** Surgeon of the General Surgery Service, Hospital Aeronáutico Central.<br />

*** General Surgery Resident, Hospital Aeronáutico Central.<br />

Received: January 18 th , 2012. Accepted: February, 15 th , 2012.<br />

Introduction<br />

Amy<strong>and</strong>’s hernia is characterized by the presence<br />

of the cecal appendix as content of the <strong>in</strong>gu<strong>in</strong>al<br />

hernia, <strong>and</strong> it has low frequency (0.13% of the<br />

cases)(7,8,10,11). It usually presents as a<br />

complicated <strong>in</strong>gu<strong>in</strong>al hernia. The acute<br />

appendicitis diagnosis is generally obta<strong>in</strong>ed dur<strong>in</strong>g<br />

the <strong>in</strong>traoperative period. It has been named after<br />

Claudio Amy<strong>and</strong> (surgeon of K<strong>in</strong>g George II), who<br />

was the first to describe the presence of a<br />

perforated appendix related to a fistula with<strong>in</strong> the<br />

<strong>in</strong>gu<strong>in</strong>al hernial sac of an eleven-year-old child<br />

of approximately 4x4 cm., is irreducible <strong>and</strong> grows<br />

<strong>in</strong> size with the Valsalva maneuver.<br />

An urgency surgical conduct is decided (photos 1<br />

<strong>and</strong> 2), with presumptive diagnosis of obstructed<br />

<strong>in</strong>gu<strong>in</strong>al hernia. In the surgery, acute <strong>in</strong>traherniary<br />

appendicitis is identified. An appendectomy <strong>and</strong><br />

anatomical <strong>in</strong>gu<strong>in</strong>al hernioplasty are carried out.<br />

The patient evolves favorably dur<strong>in</strong>g the<br />

postoperative period.<br />

(1,5).<br />

Objectives<br />

Case presentation <strong>and</strong> literature reviewed.<br />

Case Report<br />

38-year-old, male patient who consults about a<br />

pa<strong>in</strong>ful tumor <strong>in</strong> the right <strong>in</strong>gu<strong>in</strong>al region, <strong>and</strong> 4-<br />

hours evolution sickness <strong>and</strong> vomits. The tumor,<br />

Photo 1. Intraherniary cecal appendix.<br />

14


Algieri et al, Hosp Aeronáut Cent 2012; 7(1): 14-15.<br />

When the appendix is found to be normal, the<br />

appendectomy is not recommended; only viscera<br />

reduction <strong>and</strong> herniary sac treatment are<br />

recommended. If acute appendicitis is found out,<br />

appendectomy through the herniary sac is<br />

suggested, <strong>in</strong> absence of <strong>in</strong>fection with<strong>in</strong> the<br />

abdom<strong>in</strong>al cavity (1,2,4,8,9,12) or exploratory<br />

laparotomy to clean <strong>and</strong> place dra<strong>in</strong>age after the<br />

appendectomy through this surgical approach<br />

(4,10,12).<br />

Photo 2. Intraherniary cecal appendix.<br />

Discussion<br />

An hernia is the protrusion of viscera or part of<br />

them through the abdom<strong>in</strong>al wall. In the <strong>in</strong>gu<strong>in</strong>al<br />

region, the herniary sac may conta<strong>in</strong> the omentum<br />

or <strong>in</strong>test<strong>in</strong>e. However, certa<strong>in</strong> unusual content<br />

may be found, such as the bladder, a Meckel’s<br />

diverticulum (Littré’s hernia), or a portion of the<br />

<strong>in</strong>test<strong>in</strong>e circumference (Richter hernia).<br />

Amy<strong>and</strong>’s hernia refers to the presence of the<br />

appendix with<strong>in</strong> the herniary sac (5,8,10). It is really<br />

difficult to reach a cl<strong>in</strong>ical diagnosis of Amy<strong>and</strong>’s<br />

hernia before the operation. The typical<br />

characteristic of this type of hernia is pa<strong>in</strong> <strong>in</strong> the<br />

abdom<strong>in</strong>al right lower quadrant, related to a<br />

sensitive, tense <strong>and</strong> irreducible mass <strong>in</strong> the<br />

<strong>in</strong>gu<strong>in</strong>al region. However, with this cl<strong>in</strong>ical<br />

presentation the diagnosis is easily mistaken for<br />

that of a complicated <strong>in</strong>gu<strong>in</strong>al hernia, be<strong>in</strong>g this<br />

one the most important differential diagnosis.<br />

Occasionally it is possible to recognize the typical<br />

prodromal symptoms of an appendicitis such as<br />

epigastric or periumbilical pa<strong>in</strong>, that later migrate<br />

towards the right iliac fossa <strong>and</strong>/or the <strong>in</strong>gu<strong>in</strong>al<br />

region (6,7,8,12). Therefore, the diagnosis is made<br />

dur<strong>in</strong>g the surgery while the patient is subjected to<br />

surgical exploration due to a complicated <strong>in</strong>gu<strong>in</strong>al<br />

hernia (3,7,8,12).<br />

References<br />

1. Amy<strong>and</strong> C. Of an <strong>in</strong>gu<strong>in</strong>al rupture, with a p<strong>in</strong> <strong>in</strong> the appendix<br />

caeci <strong>in</strong>crusted with stone; <strong>and</strong> some observations on wounds<br />

<strong>in</strong> the guts. Phil Trans R Soc Lond 1736;39:329-42.<br />

2. Franko J, Raftopoulos I, Sulkowski R. A rare variation of<br />

Amy<strong>and</strong>’s hernia. Am J Gastroenterol. 2002; 97(10):2684-5.<br />

3. Greenberg J, Arnell TD. Diverticular abscess present<strong>in</strong>g as<br />

an <strong>in</strong>carcerated <strong>in</strong>gu<strong>in</strong>al hernia. Am Surg 2005; 71: 208-209.<br />

4. Hiatt JR, Hiatt N. Amy<strong>and</strong>’s hernia. N Engl J Med 1988;<br />

318(21):1402.<br />

5. Hutch<strong>in</strong>son R. Amy<strong>and</strong>’s hernia. J R Soc Med 1993; 86:<br />

104-105<br />

6. Irv<strong>in</strong> T. Abdom<strong>in</strong>al pa<strong>in</strong>: a surgical audit of 1190emergency<br />

admissions. British Journal of Surgery 1989;76: 1121-1125.<br />

7. Lawrence I, Chad F. Acute appendicitis <strong>in</strong> a femoral hernia:<br />

an unusual presentation of a gro<strong>in</strong> mass. The Journal of<br />

Emergency Medic<strong>in</strong>e 2002; 23: 15-18.<br />

8. Logan MT, Nott<strong>in</strong>gham JM. Amy<strong>and</strong>’s hernia: a case report<br />

of an <strong>in</strong>carcerated <strong>and</strong> perforated appendix with<strong>in</strong> an <strong>in</strong>gu<strong>in</strong>al<br />

hernia <strong>and</strong> review of the literature. Am Surg. 2001;67(7):628-9.<br />

9. Luch JS, Halpern D, Katz DS. Amy<strong>and</strong>’s hernia: prospective<br />

CT diagnosis. J Comput Assist Tomogr 2000; 24:884-6.<br />

10. Orr KB. Perforated appendix <strong>in</strong> an <strong>in</strong>gu<strong>in</strong>al hernial sac:<br />

Amy<strong>and</strong>’s hernia. Med J Aust 1993; 159: 762-763.<br />

11. Osorio JK, Guzman-Valdivia G. Ipsilateral Amy<strong>and</strong>’s <strong>and</strong><br />

Richter’s hernia, complicated by necros<strong>in</strong>g fascitis. <strong>Hernia</strong><br />

2006; 10: 443-446.<br />

12. Thomas WE, Vowles KD, Williamson RC. Appendicitis <strong>in</strong><br />

external hernias. Ann R Coll Surg Engl. 1982;64:121-2.<br />

Hospital Aeronáutico Central 15

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