An Infantile Left Amyand Hernia: Case Report and Review of Literature

Introduction

Amyand’s hernia is an inguinal hernia which contains the appendix but it is rare in pediatrics, especially during infancy [1, 2]. The first surgeon who described this phenomenon in 1735, is Dr. Claudius Amyand, Sergeant to King George II of England. He reported a child whose age was 11-years old with an enterocutaneous fistula due to a perforated appendix by a pin within the hernial sac. The primary repair of hernia and appendectomy were done within half an hour [3]. Amyand hernia is usually diagnosed intraoperatively as it is rare and its presentation is as any inguinal hernia except in case of incarceration in which erythema and tenderness are the usual signs [2]. Herein, our case is a 9-month-old male had left incarcerated Amyand hernia.

A nine-month-old infant attended to our emergency complaining of vomiting, irreducible left inguinal hernia 8 hours ago. Examination showed normal vital signs, an irreducible left inguinal hernia, distended abdomen without peritonitis. Ultrasound showed intestine within the hernia sac and his laboratory investigations were normal. Dilatation of small intestine was detected in an abdominal x-ray. Manual reduction failed so groin exploration was considered.

After induction of general anesthesia, a left inguinal transverse skin incision was done followed by opening the sac showing the congested appendix and cecum (Figure

1). The appendix was not removed as it was normal but reduction of the hernia contents into the abdominal cavity and left herniotomy were done. The patient had an uneventful postoperative course.

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Retrospectively, a chest-abdominal X-ray detected normal gas distribution in the colon which was an indicator of a hypermobile cecum rather than of abnormal gut rotation. Two days postoperatively, he was stable and discharged. Over one year follow-up, no recurrence and or testicular atrophy were detected.

Discussion

The inguinal hernia has the appendix as a content is defined as Amyand’s hernia [4]. This study case is left Amyand’s hernia. Among general population in the literature, its incidence is 0.4–0.6 % and increases to be 1 % in pediatrics [4]. The appendix is mostly detected in the right hernia sac with the large gut either cecum and/or right colon. Left Amyand’s hernia is rare, and only reported in 13 pediatric cases [5, 6, 7, 8, 9, 10, 11]. The data of all 15 pediatric patients that have been reported in literature beside our case, with a left Amyand’s hernia in (Table 1).

As regard the preoperative imaging studies, ultrasound was requested in three cases and our study case without detection of the contents except in our case, the gut was shown (data not illustrated). Detection of ileocecum and or appendix within left Amyand’s hernias has been reported in some adult patients using Contrast-enhanced computed tomography (CT) and contrast enema [12, 13, 14]. This preoperative radiography would be helpful for detection of left Amyand’s hernia and its associated intestinal anomalies, but it is not beneficial as the clinical examination is enough for undergoing emergency operation which is mandatory.

Intraoperative suspicion of the left sided ileocecum as a content of the sac should be considered by surgeons as mentioned in the majority of this review cases. Appendicitis is rare to be seen in Amyand’s hernia which is usually due to ischemia and or trauma of incarceration [15]. Appendectomy was done for 4 out of 15 pediatric patients having a left Amyand’s hernia and showed appendicitis (Table 1). The other eleven cases, involving our case, had a normal appendix (seven appendices were left; four were resected). According to literature, the presence of the appendix within the sac is not an indication of appendectomy except if it is inflamed. Removal of the normal appendix is controversial as follows: (1) the proposed surgical wound infection [4]; (2) the enlargement of wound to control the appendiceal base leading to the abdominal wall weakness and a possible recurrence [16]; and (3) loss of the benefit of the appendix for possible urinary diversion (Mitrofanoff appendicovesicostomy) [6].

One pediatric case with a left Amyand’s hernia underwent an intraoperative abdominal search for the possible anomalies [8], which revealed a mobile cecum. Recently, laparoscopy has an advantage over conventional approach in case of incarcerated inguinal hernia for reduction and visualization [17]. In literature, laparoscopy was successfully used for management of an adult right-sided Amyand’s hernia [18]. Hence, laparoscopy could be advantageous for left hernias in pediatrics, to confirm the abovementioned possible anomalies intraoperative.

Regarding to proposed detection of the abovementioned anomalies, no management is expected for situs inversus or mobile cecum whereas intestinal malrotation may need surgery as Ladd’s procedure if there is a history of obstruction due to possible volvulus.

Conclusion

The left-sided Amyand hernia is rare in pediatrics which could be managed in form of herniotomy and appendicectomy in case of infection and/or trauma with many advantages of laparoscopic management. The associated anomalies as a mobile cecum, intestinal malrotation, or situs inversus should be investigated through intra- or postoperative imaging studies.