Appendicitis in paraumbilical hernia mimicking strangulation: a case report and review of the literature

Purpose

The contents of umbilical or paraumbilical herniae are usually omentum or bowel; rarely, metastatic deposits, appendix epiploicae, or an inflamed vermiform appendix may be found. Unexpected contents cause confusion in the diagnosis, especially when inflamed, and may mimic a strangulated umbilical hernia. Appendicitis in the hernial sac is known in inguinal and femoral herniae; however, only four reported cases of appendicitis within an umbilical hernia could be identified.

Case

A 54-year-old female presented to the emergency with a 2-day history of vomiting, severe pain and irreducibility of a paraumbilical swelling. On examination, we found tachycardia, with a tender, erythematous and irreducible paraumbilical swelling. With a diagnosis of strangulated paraumbilical hernia, the abdomen was explored through an infraumbilical incision. Opening the sac revealed inflammatory fluid, omentum, and an inflamed and edematous appendix. Appendicectomy was performed with anatomical double-breasted repair of the fascial defect. Histopathological examination of the specimen revealed acute appendicitis, periappendicitis and panniculitis in the omentum.

Conclusion

Appendiceal inflammation inside a hernia sac is probably due to extrinsic compression and partial ischemia. Symptoms manifest late, and the final diagnosis is mostly made during the operation. CT scan provides only indirect clues to diagnosis. Appendicectomy and anatomical repair is the appropriate treatment for appendicitis within a paraumbilical hernia.     

Clinical significance of de Garengeot's hernia: A case of acute appendicitis and review of the literature

IntroductionThe presence of the appendix in a femoral hernia sac is known as de Garengeot's hernia. We report a rare case of an elderly woman with femoral hernia appendicitis and discuss the surgical pitfalls and considerations through a literature review.Presentation of caseAn 83-year-old woman presented with fever and right lower quadrant abdominal pain. Clinical examination revealed a femoral hernia. Ultrasonography confirmed bowel was present in the hernia sac. In the operation room, an acutely inflamed appendix was recognized within the sac. The patient underwent appendectomy and hernia repair with sutures.DiscussionAcute appendicitis within a femoral hernia is rare and multiple dilemmas exist regarding its treatment. An incision below the inguinal ligament is a reasonable choice in order to access the hernia sac. A mesh should be placed in non-infectious appendectomy while herniorrhaphy is preferred in cases of appendicitis.ConclusionThe presence of the vermiform appendix in a femoral hernia sac is rare but the surgeon should be aware of this clinical entity. Prompt diagnosis and appropriate surgical treatment is the key to avoid complications.     

A case report of incarcerated inguinal hernia: Amyand’s hernia with adenocarcinoma tumor

IntroductionInguinal hernia is one of the most common surgical problems, often posing technical challenges even to expert surgeons. Amyand’s hernia (AH) is an inguinal hernia whose sac contains the vermiform appendix. Primary appendiceal neoplasms are rare. We report the case of an appendiceal adenocarcinoma within an Amyand’s hernia, presenting as an incarcerated right inguinal hernia.Presentation of caseA 87-year-old male presented in the emergency department due to a persistent right inguinal pain. Clinical examination revealed a tender right groin mass. Under the diagnosis of an right inguinal hernia, an operation was taken. Intraoperatively, an inflamed appendix and a part of the cecum were found in the hernia sac. The operation was completed with an ileocecal resection and a modified Bassini hernia repair. Histological examination revealed a adenocarcinoma of the appendix.DiscussionAmyand’s hernia is an inguinal hernia that contains vermiform appendix in its sac. It consists 1% of all inguinal hernias while appendicitis in an Amyand’s hernia accounts for 0.1% of all appendicitis cases. Adenocarcinomas of the appendix are even rarer, accounting for 0.2% to 0.5% of all intestinal malignancies, and 4%–6% of primary appendiceal neoplasms. Diagnosis is usually established intraoperatively.ConclusionA malignancy of the appendix should always be in the differential diagnosis of a right inguinal mass, in order to provide optimum surgical treatment.     

Elective laparoscopic surgery for sigmoid colon carcinoma incarcerated within an inguinal hernia: report of a case

Primary colon carcinoma within an inguinal hernia sac is very rare and most reported cases were found at emergency open surgery for an incarcerated hernia. We report a case of incarcerated sigmoid colon carcinoma diagnosed preoperatively and treated with elective laparoscopic surgery. A 67-year-old man with a 2-year history of swelling of the scrotum and a breast lump was referred to us for surgical treatment of an irreducible left inguinal hernia and a right breast tumor. Blood examination results showed severe anemia. Computed tomography scan and endoscopic biopsy confirmed sigmoid colon carcinoma incarcerated in the left inguinal hernia. Thus, we performed definitive laparoscopic sigmoidectomy and conventional hernia repair for preoperatively diagnosed sigmoid colon carcinoma within an inguinal hernia.     

Amyand’s Hernia in a 76-year-old Greek Male

The presence of an inflamed or non-inflamed appendix in an inguinal hernial sac is called Amyand’s hernia and it is a rare condition. The case is presented here of a 76-year-old Greek male with a known right reducible inguinal hernia, who presented at the hospital emergency department with the symptoms and signs of incarceration of the hernia. Intraoperatively, an inflamed appendix was revealed trapped in the hernial sac. To our knowledge this is the first case of Amyand’s hernia reported in a patient in Southwestern Greece.     

Case Report: a Rare Case of Amyand’s Hernia Presenting in a 3-year-old Male Child

The finding of the vermiform appendix in an inguinal hernia has an incidence of approximately 1 %. The condition is given the eponymous name “Amyand’s hernia.” However, in just 0.08 %, the condition is complicated by an acute appendicitis. The clinical presentation varies, depending on the extent of inflammation of the appendix, and is most often misdiagnosed as an incarcerated inguinal hernia. As such, it is rarely recognized prior to surgical exploration. We report a case of Amyand’s hernia in a 3-year-old child who presented as a right-sided congenital hernia with pain in the right groin. He underwent herniotomy, which revealed that the hernia sac containing elongated inflamed appendix appeared with some adhesions to sac, lying in the inguinal canal.     

Amyand’s hernia: a report of 18 consecutive patients over a 15-year period

Aim The presence of a vermiform appendix in an inguinal hernia sac is termed Amyand’s hernia. It may present as a tender inguinal or inguino-scrotal swelling and is often misdiagnosed as an incarcerated or strangulated hernia. The purpose of this study was to review the management of Amyand’s hernia at a single institution since 1991. Material and methods A retrospective analysis was undertaken of 18 consecutive patients with an Amyand’s hernia operated upon at our institution from 1991 to 2005. Patients’ demographics, treatment and postoperative outcome were analysed. Results There were 17 men and one woman. Their median age was 42 years. None of the patients was diagnosed preoperatively. The commonest presenting symptom was painful inguinal or inguino-scrotal swelling (83%). All patients, therefore, underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated inguinal hernia. Operative findings included 11 normal appendices, four inflamed appendices and three perforated appendices in the inguinal hernial sac. Patients with a normal appendix (n = 11) had a mesh hernia repair without an appendicectomy. The rest of the patients (n = 7) with an abnormal appendix underwent emergency open appendicectomy followed by Bassini’s sutured hernia repair. One patient died in the postoperative period of pneumonia. Only one recurrent hernia has been detected, with a median follow-up time of 6.4 years. Conclusion The inflammatory status of the appendix determines the type of hernia repair and the surgical approach. Incidental appendicectomy in the case of a normal appendix is not favoured.     

Left inguinal appendix in an HIV patient: A case report and review of literature

INTRODUCTIONThe presence of the appendix in an inguinal hernia sac is rare, with an estimated incidence of 0.51–1% of all inguinal hernias. An inguinal appendix is most commonly referred to as Amyand's hernia.PRESENTATION OF CASEA 59-year-old HIV positive male presented to our center with a left painful inguinal mass. The preoperative diagnosis was a left inguinal hernia. Intraoperatively, the sac was found to contain a non inflamed appendix; the appendix was reduced back to the peritoneal cavity and the patient underwent a tension free prosthetic left inguinal hernia repair.DISCUSSIONMost cases of inguinal appendices are right-sided and are diagnosed intraoperatively; left-sided cases as we encountered are rare and most likely the result of cecal mobility. Preoperative diagnosis of the entity is difficult and most cases are diagnosed intraoperatively. A CT scan is not necessary unless other pressing differentials need to be ruled out. Most authors agree that if the appendix is not inflamed, appendectomy, concurrently with herniorrhaphy, should not be performed to avoid perioperative septic complications.CONCLUSIONSurgical management of inguinal appendices carries a risk of septic complications. This is especially pertinent to our case, considering the immunocompromised status of our patient. The decisions in the operating room were geared toward limiting septic potential.     

Amyand’s hernia and peri-appendicular abscess in primary care

We report an unusual case of peri-appendicular abscess occurring in an irreducible Amyand's hernia, managed in a primary care setting. An 84-year-old gentleman, with severe chronic obstructive airways disease, was assessed in a Primary Care surgical clinic and found to have a moderate-sized, tender, irreducible right inguinal hernia. He underwent immediate surgery under local anaesthetic. He was found to have a peri-appendicular abscess and perforated appendix within a right indirect inguinal hernia sac. Appendicectomy and sutured hernia repair were performed under local anaesthesia.     

Amyand’s hernia in premature neonates: report of two cases

The finding of a normal or inflamed vermiform appendix within an inguinal hernia is termed Amyand’s hernia. It is extremely rare in children, especially in infants and neonates. When it occurs, it is usually misdiagnosed as an irreducible or strangulated inguinal hernia, and the accurate diagnosis is made intraoperatively. We report two cases of Amyand’s hernia in premature neonates. Both patients presented on admission with signs and symptoms indicating a strangulated right inguinal hernia, and the accurate diagnosis was made intraoperatively. One of them had progressed to local peritonitis. Appendicectomy and hernia repair were made at the same time through an inguinal transverse incision, and the postoperative course was uneventful in both. We point out the need to consider acute appendicitis in the differential diagnosis of strangulated right inguinal hernia.     

Laparoscopic reduction of Amyand's hernia

Summary The discovery of a vermiform appendix in an inguinal hernia sac is not uncommon, occurring in 1% of inguinal hernia repairs. However, the discovery of an acutely inflamed appendix within any hernia sac occurs in only 0.13% of cases. This rare finding is known as Amyand's hernia. We present a case of Amyand's hernia which was diagnosed preoperatively by CT scan and was reduced laparoscopically.     

Amyand’s hernia: a series of 30 cases in children

Amyand’s hernia is a very rare condition with a presence of a vermiform appendix in an inguinal hernia sac. It is estimated to be found in approximately 1% of adult inguinal hernia. In this study, we report a retrospective analysis of 30 patients aged between 19 days and 8 years with an Amyand’s hernia operated in our institution from 1998 to 2009, and we reviewed the literature on the topic. Hernia repair without an appendectomy was performed in patients with normal appendix. Emergency appendectomy through herniotomy was performed in cases of inflamed and perforated appendices.     

De Garengeot hernia with perforated appendicitis and a groin subcutaneous abscess: A case report

IntroductionDe Garengeot hernia is rare. Although previous reports have suggested various surgical options according to patient condition, comorbidities, surgeon preference, and clinical findings during surgery, a treatment strategy has not been established.Presentation of caseAn 81-year-old woman presented with an irreducible tender mass that was subsequently diagnosed as an incarcerated femoral hernia with a subcutaneous abscess in the right groin. Intraoperative findings revealed a necrotic and perforated appendix strangulated by the femoral ring for which an appendectomy and herniorrhaphy was performed concurrently through the hernia sac. The subcutaneous abscess cavity was washed thoroughly and a drainage tube was placed within it. The patient recovered uneventfully.DiscussionWe suggest that the approach through the inguinal incision in both appendectomy and herniorrhaphy with drainage may be useful in avoiding intra-abdominal contamination in cases of de Garengeot hernia with subcutaneous abscess.ConclusionHere, we described a case of de Garengeot hernia with a subcutaneous abscess in the groin. Clinicians should consider de Garengeot hernia in patients with a groin hernia, make an early diagnosis, and promptly provide surgical treatment to reduce the risk of complications.     

Carcinoma of the sigmoid presenting as a right inguinal hernia

We present the case of a 44-year-old man who presented with nausea, vomiting and acute pain in the right groin. On physical examination an irreducible mass was palpated in the right inguinal region. Ultrasound suggested an inguinal hernia sac with bowel contents. Subsequent right inguinal exploration revealed only unspecified necrotizing tissue, but no hernia sac or bowel contents were identified. Two days later laparotomy was required since the inguinal wound produced faecal discharge. The sigmoid appeared to be necrotic and perforated, and was subsequently resected. Histology revealed a perforated adenocarcinoma without lymph node involvement. Incarcerated inguinal hernias containing an adenocarcinoma of the colon are rare, but should be considered in patients presenting with an irreducible palpable mass in the inguinal region. Moreover, a carcinoma of the sigmoid may invade the right inguinal region. An intestinal perforation to skin-level in this population is even rarer and is associated with high morbidity and mortality rates.     

Sliding appendiceal inguinal hernia with a congenital fibrovascular band connecting the appendix vermiformis to the right testis

It is not uncommon to find the appendix vermiformis within a hernia sac; however, sliding appendiceal inguinal hernia is rare. A 9-month-old boy with an incarcerated right scrotal hernia is presented in this case report. Although the hernia was reduced through a conservative approach, appendix vermiformis remained in the hernia sac because of its attachment to the upper pole of the right testis. Exploratory surgery during the inguinal hernia repair revealed a connecting band that extended from the appendix vermiformis into the scrotum and attached to the right testicle. Histologic examination showed that the band was congenital. After reduction of an incarcerated hernia, the persistence of a thickened or a cord-like structure is a warning for the presence of a sliding hernia. We suggest that this uncommon developmental anomaly is likely to cause the processus vaginalis to remain patent, thus facilitating hernia formation. Electronic Publication     

Amyand’s hernia — Always an operative surprise

Acute appendicitis in an inguinal hernia is termed an Amyand’s hernia. This is an extremely rare condition that is often misdiagnosed. It may present as a tender inguinal or inguinoscrotal swelling. The clinical presentation varies depending on the extent of inflammation in the hernia sac and associated peritoneal contamination. The authors report a rare case of Amyand’s hernia in a 2-month-old boy who presented with features of a strangulated right inguinal hernia. The patient was successfully managed with strict adherence to the basic principles of resuscitation and stabilisation before surgery. Our aim is to highlight the rare presentation of a common disease and to review the relevant available literature. In paediatric patients with Amyand’s hernia, the type of hernia repair and the operative approach is determined mainly by the inflammatory status of the appendix. Incidental appendicectomy in the case of a normal appendix is not favoured. However, in cases of children with an inflamed or complicated appendix, treatment includes appendicectomy (via the hernia sac) and hernia repair. After reviewing the literature, authors emphasise the extreme rarity of the case, underlining the diagnostic dilemma it creates.     

Endoscopic total extraperitoneal management of Amyand’s hernia

Presence of an appendix in a hernial sac (Amyands hernia) is a rare entity, still rarer is an inflamed appendix within the hernial sac. An endoscopic total extraperitoneal repair of a right-sided incarcerated inguinal hernia is described. The inguinal hernial sac contained an inflamed appendix. An associated small incisional hernia at the lower end of a midline suprapubic scar for a Millins prostatectomy was simultaneously repaired.     

Perforated Carcinoma of the Sigmoid Colon in an Incarcerated Inguinal Hernia: Report of a Case

Perforation of the large bowel due to benign or malignant disease in an inguinal hernia is very rare, but should be considered as a potential cause of strangulated hernias. A 79-year-old man with a 2-day history of scrotal swelling and pain in the left side associated with fever and chills was brought to our Emergency Department, where he was classified as American Society of Anesthesiologists IVE. A large left incarcerated scrotal hernia was diagnosed and surgical exploration was performed using local infiltration anesthesia. A standard oblique inguinal incision was made, revealing perforation of the sigmoid colon due to cancer. A 40-cm segmental resection of the sigmoid colon was done, and a double-barrel colostomy was made through the inguinal incision. This surgical strategy involving construction of a double-barrel colostomy through the inguinal hernia incision could be an alternative method of managing such critically ill patients.     

Perforated appendix in hernial sac mimicking torsion of undescended testis in a neonate

In pediatric surgical practice, finding of the vermiform appendix in an inguinal hernia sac is not that uncommon; however, a perforation is rare. There are only a few case reports of a perforated appendix with periappendicular abscess in the inguinal hernial sac in a neonate. We report an unusual case of inguinal hernia containing a perforated appendix that was clinically mimicking testicular torsion of the undescended testis.