ONLINE CASE REPORT

Ann R Coll Surg Engl 2021; 103: e50–e52

doi 10.1308/rcsann.2020.7000

Appendiceal hernia: an extremely rare condition

GA Molina1, CL Rojas2, WG Aguayo2, MA Moyon2, P Gálvez2, EC Polanco2, LP Novoa2,
VL Reveló2

1
Universidad San Francisco de Quito USFQ & Hospital del IESS Quito, Sur, Ecuador
2
Hospital San Francisco de Quito – IESS, Ecuador

ABSTRACT
Appendix-associated hernias are extremely rare. They have been described sporadically in the literature, mostly as inguinal hernias. Appendix-associated
incisional hernias are even more unusual. High clinical awareness is needed as complications can arise if misdiagnosis or delay occurs. We present an
80-year-old man with acute appendicitis in an incisional hernia. After successful surgery, the patient made a full recovery.

KEYWORDS
Acute appendicitis – Incisional hernia – Hernia surgery
Accepted 5 July 2020
CORRESPONDENCE TO
Gabriel Molina, E: [email protected]

Case history (Prolene, Ethicon, Somerville, NJ, USA). A mesh was

considered but ruled out due to the high risk of infection.
Our patient was an 80-year-old man with a past medical Pathology reported acute appendicitis.
history of open cholecystectomy, prostatectomy and The postoperative period was uneventful. A liquid diet
bilateral inguinal hernia repair. At the site of his Kocher was initiated on the first postoperative day and was
incision, he had a 2×2cm incisional hernia diagnosed followed by a full diet. The patient was discharged on his
35 years ago. As he was asymptomatic, he never sought third postoperative day without complications. Six
medical attention. months later, the patient is doing well and has no hernia
He presented to the emergency room with a three-day recurrence.
history of upper abdominal pain, asthenia, nausea and
vomiting. On clinical examination, he was febrile,
tachycardic and dehydrated. He had a 3×2cm
non-reducible painful mass around the Kocher incision,
with pain on touch and tenderness.
Examination revealed mild leucocytosis without
neutrophilia. Abdominal echography was inconclusive.
Contrast-enhanced abdominal computed tomography
(CT) revealed a 2×2cm abdominal wall defect over the
previous Kocher incision. The hernia sac contained an
inflamed appendix; its wall measured over 6mm and had
slight fat enhancement (Figure 1). The diagnosis was
acute appendicitis within an incarcerated incisional
hernia.
The patient had a surgical consultation, and surgery
was planned. At surgery, a 2×2cm abdominal wall defect
was identified over the previous incision. The hernia sac
was opened, unveiling the caecum and appendix. On
gross examination, the appendix measured 12cm in
length and 0.7cm in diameter. The external surface of
the appendix was pink and showed congestion (Figures 2
and 3). Figure 1 Computed tomography: the appendix is seen in the hernia
Appendectomy was completed, and the abdominal wall sac
defect was sutured using a 1-0 non-absorbable suture

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MOLINA ROJAS AGUAYO MOYON GÁLVEZ POLANCO NOVOA REVELÓ APPENDICEAL HERNIA: AN EXTREMELY RARE CONDITION

Figure 2 Appendix during surgery Figure 3 Appendectomy

Discussion previous surgery.1,3 When the appendix is in an

The presence of the appendix within an anterior wall abdominal wall hernia, it is usually in the inguinal
hernia, inflamed or not, was first reported by Claudius (Amyand hernia) or femoral (De Garengeot hernia) canal
Amyand in 1735.1,2 This rare phenomenon (incidence on the right side.1,3, 4 It is extremely rare to encounter
0.51%) is thought to be caused by atypical positions of the the appendix in an incisional hernia. This has been
caecum and appendix, malrotation of the intestine or described in limited case reports, mostly in Pfannenstiel

Table 1 Previous case reports from acute appendicitis within incisional hernias

Age / Preoperative Perforated

Ref. sex Presentation Hernia location diagnosis Outcome appendix Mesh Approach
6 71 F Lower abdominal pain Previous CT Complete Yes No Open
and mass ileostomy recovery
7 N/A F Abdominal pain Port-site hernia N/A N/A Yes No Open
8 27 F Abdominal pain Pfannenstiel CT Complete No No Laparoscopic
recovery
9 78 M Abdominal pain Midline CT Complete No Biological Open
recovery
81 M Abdominal pain Port-site hernia CT Complete No N/A Open
recovery
10 48 F Abdominal pain Pfannenstiel CT Complete No No Laparoscopic
recovery
11 57 M Abdominal pain Lumbotomy CT Complete No Polypropylene Open
incision recovery
12 37 F Upper abdominal pain Port-site hernia CT Complete No Polypropylene Open
recovery
13 62 F Abdominal pain Pfannenstiel Abdominal x-ray Complete Yes No Open
recovery
14 51 F Nausea, bloating, Ventral hernia CT Complete Yes No Laparoscopic
intermittent vomiting, recovery
fever, diarrhoea
15 70 F Lower abdominal pain, Incisional hernia CT Complete No No Open
constipation over right iliac recovery
crest

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MOLINA ROJAS AGUAYO MOYON GÁLVEZ POLANCO NOVOA REVELÓ APPENDICEAL HERNIA: AN EXTREMELY RARE CONDITION

incisions, umbilical hernias, trocar entry sites, Spigelian complications due to delayed perioperative diagnosis and
hernias and upper midline laparotomies (Table 1).1,5 treatment is high due to the low incidence and atypical
In our patient, we detected the appendix in the previous clinical presentation. It is possible for the appendix to
Kocher incision, an event that has not been described in become incarcerated in any abdominal wall hernia, and
the literature. We speculate that his previous surgery surgeons should always be aware of these rare entities,
may have created adhesions, leading to the unusual since delay can potentially change the outcome.
location of the appendix.
Unlike routine appendicitis, it is thought that extraluminal
compression leads to acute inflammation; however, primary
appendicitis can still occur.1,2 The clinical presentation of this References
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