Amyand´s hernia: playing hide and seek
Woman of 53 years old with no known drug allergies and no medical or surgical history of interest. Enquiry for second time in the Emergency Department presenting generalized abdominal pain of about 7 days of evolution, associating low-grade fever without nausea, vomiting or intestinal transit. Physical examination shows pain in the hypogastrium and in the right iliac fossa with signs of peritoneal irritation that are doubtful at that level. In the laboratory, intense leukocytosis with associated neutrophilia stands out. Ultrasonography is requested due to the suspicion of appendicopathy, where a normal cecal appendix is seen, located in the inguinal position and with pain to its compression. Facing these findings (localization and pain) Amyand’s hernia with acute appendicopathy is suspect, so the study is extended with abdominal CT, showing a retropendicular collection that extends to posterior planes reaching the adipose tissue of the rectosigmoid junction, with changes suggestive of perforation. Alfo, thickening and internalized appendiceal enhancement in theright inguinal canal in relation to inflammation, in context of Amyand’s hernia.
The patient was operated by exploratory laparoscopy with finding of acute apendicitis with distal abscss, performing a laparoscopic appendectomy with drainage of the abscess and washing of the abdominal cavity. Good posterior and high evolution without incidents.
Discusion:
The Amyand hernia is a type of inguinal hernia characterized by the presence of the vermiform appendix in the hernia sac. It is between 0.4 and 1% of all inguinal hernias and can be associated with appendicitis (it accounts for 0.1% of all cases of appendicitis). The Amyand hernia appears in 11% of patients with Meckel's diverticulum and is three times more common in the pediatric population. They are usually found on the right side, given the situation of the appendix, however, it is believed that left hernias can also occur.Its clinical presentation varies significantly and can range from asymptomatic cases, especially in the pediatric population, to signs and symptoms of complicated inguinal hernia. Although it is more rare, it can also present as acute scrotal symptoms. Establishing a precise and timely diagnosis remains a challenge and requires a high index of clinical suspicion. Computed tomography and ultrasound have been shown to help establish an accurate diagnosis when suspected.
There is controversy about which is the best treatment for Amyand's hernia. Traditionally, appendectomy was practiced prophylactically together with hernioplasty. However, there is a lack of agreement about the optimal management of these patients, with the degree of infection, inflammation and perforation determining the performance.
In terms of morbidity and mortality, when the Amyand hernia is adequately treated, they coincide with that of the typical hernia. We have a pathology very rare but with a very frequent and non-specific semiology. The correct anamnesis, physical examination and rational use of the imaging tests will be the key to establish the adequate diagnosis.
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