Amyand’s Hernia: A Case Report and Review of the Literature

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Introduction and Importance

A hernia forms when an organ or its fascia protrudes through the wall of the cavity.¹ An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. The contents of the inguinal hernial sac may include intraperitoneal fat, small, or large bowel, bladder, ovaries, and appendix.² Amyand’s hernia (AH) is defined as an inguinal hernia containing the appendix within the hernial sac.³ The incidence of this rare disease is up to 1% of all cases of inguinal hernias.⁴ Claudius Amyand was the first surgeon to describe and treat it in 1735.⁵ It is more common in males (90% of patients), and on the right side because of the normal location of the appendix and the increased inguinal hernia on the right side.⁶ It is clinically difficult to differentiate AH from an inguinal hernia due to their similar presentations. An AH is a diagnostic challenge due to its rarity, and diagnosis is often incidental, on imaging or intraoperatively.⁷

Case Presentation

Patient Information: A 44-year-old male presented to the surgical department outpatient clinic with a complaint of a painful swelling in the right inguinal region for the past 5 years. Initially, it was small and gradually increased in size over time, and developed pain. There was no history of abdominal pain or vomiting, and the patient did not seek any medical advice for it previously, as this swelling had been present for a long time, causing no symptoms.

Physical Examination: On examination, there was an incomplete, reducible indirect right inguinal hernia with a positive cough impulse.

Diagnostic Assessment: The patient was clinically diagnosed with an indirect inguinal hernia. Ultrasonography also showed a right inguinal hernia. Hematologic workup was within normal limits.

Intervention: A preoperative diagnosis of right inguinal hernia was made, and a plan for hernia repair with mesh was made. Intraoperatively, the hernial sac was found to contain an appendix. The appendix was slightly congested, not inflamed, but there were dense adhesions within the sac, and so adhesiolysis and appendectomy, along with herniotomy and Lichtenstein mesh hernioplasty, were done. The postoperative period was uneventful.

Follow-Up and Outcome

Postoperatively, the patient was eating and drinking and was discharged the next day with follow-up after 1 week of surgery to remove stitches, and then after 6 weeks of surgery. On the follow-up, no hernia recurrence or mesh-related complications were noted (Figure 1).

Clinical Discussion

AH is an inguinal hernia containing the appendix inside it, regardless of the inflammation. It is classified according to Losanoff and Basson depending on the presence and spread of inflammation (Table 1).⁸ In this case, appendectomy with simultaneous hernioplasty was completed prophylactically for a potential future complication that may lead to appendicitis.⁹ The decision to keep or remove the appendix relies upon the individual’s age, endurance, and the hazards of developing acute appendicitis. The young people have a higher chance of developing acute appendicitis in comparison with elderly patients.¹⁰ Removing a healthy appendix is subject to a medical debate, which has not reached a consensus yet.¹¹ Many theories try to explain the pathology of AH; one of them suggests that it may be a congenital situation due to a fibrous connection between the right testis and appendix, with the presence of patent processus vaginalis, and this connection leading to the appendix toward the hernial sac.¹²

The underlying mechanism that causes appendicitis in an AH is not the same as that of true appendicitis. Obstruction of the appendix in an AH is caused by the extraluminal pressure of the hernia neck on the appendix rather than intraluminal obstruction.^4,8 Incarceration of the appendix secondary to the hernia neck then leads to compromised blood flow, generalized inflammation, and bacterial overgrowth.¹³ Right-sided AHs occur more often than left-sided ones due to the anatomical location of the appendix on the right. Left-sided AHs are very rare,¹⁴ although they have been reported on the left side; this is rare and may be associated with situs inversus, intestinal malrotation, or a mobile cecum.¹⁵ A normal-looking appendix in the hernial sac does not always require appendectomy. Appendectomy adds the risk of infection to an otherwise clean procedure.

Whether to remove or leave behind a normal appendix is a clinical dilemma because no evidence-based information exists. There is an ongoing debate over prophylactic appendectomy when the appendix appears normal.¹¹ Historically, surgical management of AH was primarily through an open approach. A laparoscopic approach is becoming favored due to patient benefits such as faster recovery, shorter hospital stays, and decreased postoperative pain.¹⁶ Investigations such as ultrasonography and computed tomography scan may help in preoperative diagnosis, but the final diagnosis of Amyand hernia is usually made intraoperatively.⁹ Definitive preoperative diagnosis poses a challenge due to indistinct clinical signs and symptoms. Due to the rarity of AH and the wide variety of its presentation, each case study and review article sheds light on new and useful information regarding its treatment and diagnosis.¹ This case has been reported in line with the SCARE 2025 criteria as published by Kerwan et al.¹⁷

Table 1: Losanoff and basson classification of AH.
Classification	Description	Surgical Management
Type 1	Normal appendix in an inguinal hernia	Hernia reduction, mesh repair
Type 2	Acute appendicitis in an inguinal hernia, without abdominal sepsis	Appendectomy, primary repair of hernia without mesh
Type 3	Acute appendicitis in an inguinal hernia, with abdominal wall or peritoneal sepsis	Laparotomy, appendectomy, primary repair without mesh
Type 4	Acute appendicitis in an inguinal hernia, with abdominal pathology	Manage as Type 1–3, investigate pathology as needed

Conclusion

Due to its rare nature, AH diagnosis remains a perioperative finding. The choice of surgery (appendectomy and herniotomy or hernioplasty) is surgeon-dependent, based on the presentation and difficulties encountered, as well as the consideration of therapeutic options. Although the complications of this type of hernia are rare, they can be dangerous and life-threatening. Therefore, fast and accurate diagnosis and treatment are essential. More studies are needed to understand the physiology of this rare type of hernia and to determine the best diagnosis and treatment methods. The literature review recommends reducing the hernia content and performing a tension-free hernia repair. However, in the cases where an inflamed, suppurative, or perforated appendicitis is encountered, no prosthetic material should be used because of the increased risk of surgical site infection. Nevertheless, more research is needed to provide surgeons with evidence-based standardized approaches for dealing with this unique situation to ensure optimal patient outcomes.

References

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