Edorium J Surg 2020;7:100049S05AA2020. Ayala et al.

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CASE REPORT PEER REVIEWEDOPEN ACCESS

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Laparoscopic approach to Amyand hernia: A case report

Andres V Ayala, Macarena Dávalos, Juan C Aldaz, A Gabriela Lara,
María E Chávez Ulloa, Gabriel A Molina

ABSTRACT How to cite this article

Background: Amyand’s hernia is an inguinal hernia Ayala AV, Dávalos M, Aldaz JC, Lara AG, Ulloa MEC,
containing the vermiform appendix. The herniated Molina GA. Laparoscopic approach to Amyand hernia: A
appendix can be inflamed during this stage. This rare case report. Edorium J Surg 2020;7:100049S05AA2020.
inguinal hernia presentation is named after Claudius
Amyand, the first surgeon to record an appendectomy. It
is a rare event in which symptoms and signs are usually Article ID: 100049S05AA2020
not obvious, leading to misdiagnosis, delay in treatment,
and higher complication rates. Laparoscopy has become *********
an invaluable tool for physicians, as it can accurately
diagnose and treat unexpected pathologies, such as doi: 10.5348/100049S05AA2020CR
Amyand’s hernia in an emergency setting.
Case Report: We present the case of a 31-year-old
male patient with acute abdominal pain. After clinical
examination, surgery was required, and an Amyand’s
INTRODUCTION
hernia was discovered. The laparoscopic approach
Amyand’s hernia is defined as the presence of the
successfully treated this hernia without surgical site
vermiform appendix within an inguinal hernia sac [1,
infection or complications.
2]. It is an extremely rare pathology (1% of all inguinal
Conclusion: Amyand’s hernia is an extremely rare hernias) that can lead to troublesome complications if it
presentation of an inguinal hernia. Due to its rare is misdiagnosed [3, 4]. Open appendectomy and hernia
presentations and low incidence, it can easily be missed, repair were the mainstay treatment of this rare condition.
leading to troublesome complications. However, with the advent of laparoscopic surgery, a less
invasive procedure, we can provide more significant
Keywords: Amyand’s hernia, Inguinal hernia, Laparo- advantages to our patients [1, 5]. We report the case of
scopic surgery a 31-year-old male patient. He presented with acute
abdominal pain, and laparoscopic surgery was needed to
treat him. Amyand’s hernia was detected and successfully
Andres V Ayala1, Macarena Dávalos1, Juan C Aldaz1, A
treated.
Gabriela Lara2, María E Chávez Ulloa3, Gabriel A Molina4
Affiliations: 1Attending Surgeon, MD, Department of General
Surgery at Hospital IESS Quito Sur Quito-Ecuador, Ecuador;
2
Resident, MD, Department of General Surgery at Hospital CASE REPORT
IESS Quito Sur, Ecuador; 3Intern, Department of General
Surgery at Hospital IESS Quito Sur, Ecuador; 4MD, Attend- We present the case of a 31-year-old male without
ing Surgeon, Universidad San Francisco de Quito (USFQ), past medical history. He presented to the emergency
Department of General Surgery at Hospital IESS Quito Sur room with an 18-hour history of acute abdominal pain,
Quito-Ecuador, Ecuador. nausea, and anorexia. On clinical examination, he
Corresponding Author: Gabriel A Molina, MD, Attending was tachycardic (117), febrile (38°C) and with a blood
Surgeon, Department of General Surgery at Hospital IESS pressure of 130/65. Severe pain on touch was detected
Quito Sur Quito-Ecuador, Ecuador; Email: gabomolina32@ on his lower abdomen. His pain was not migratory or
gmail.com colicky, although there was no tenderness or percussion
pain over McBurney’s point. On groins inspection,
no masses, lumps, or swellings were detected.
Received: 02 October 2020
Complementary exams, including complete blood count
Accepted: 25 November 2020
Published: 21 December 2020 and abdominal echography, were normal. Thus, he was
admitted for close surveillance. A computed tomography

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Edorium J Surg 2020;7:100049S05AA2020. Ayala et al.  2
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(CT) was considered, nonetheless as his pain persisted,

hence, surgery was decided.
At laparoscopy, a 3 × 2 cm right-sided indirect inguinal
hernia was discovered. The hernia sac was covered with the
cecum and small bowel (Figure 1A). After blunt dissection
to separate the bowel from the hernia sac, the vermiform
appendix was found within the hernia sac (Figure 1B).
After slightly dissecting the hernia sac, the appendix was
removed without complications. The appendix measured
0.3 × 6 cm and was completely normal without signs of
congestion or perforation.
From there, dissection continued, and the hernia sac
Figure 2: Transabdominal preperitoneal (TAPP) repair with
was grasped and released from the transverse fascia, and
prosthetic mesh.
dissection of the extraperitoneal space was completed. A
10 × 15 cm polypropylene mesh was placed and secured
with absorbable tacks. Afterward, the free peritoneal DISCUSSION
edges were grasped, brought up, and secured using tacks
(Figure 2). There are two sporadic events in which the vermiform
After this procedure, the appendix was re-assessed, appendix, inflamed or not, is discovered within the
and due to his clinical picture, and since the appendix inguinal (Amyand) or femoral canal (de Garengeot).
was found within the hernia sac, an incidental These hernias are named after Dr. Claudius Amyand
appendectomy was decided. His postoperative course and Dr. Croissant de Garengeot, the first physicians
was uneventful. Sips of liquids were initiated on his first who described these conditions in 1736 and 1731 [1–3].
postoperative day and then after followed by full diet. Amyand’s hernias occur in 0.4–0.6% of all inguinal
He was discharged without complications on his second hernias, and the presence of appendicitis within an
postoperative day without any pain and remained well Amyand’s hernia accounts for 0.1% of all appendicitis [1,
on close follow-ups. He resumed full activity 3 months 2]. These hernias are usually more common in children
after surgery. due to the patency of processus vaginalis in the pediatric
Pathology reported lymphoid hyperplasia with slight population [1, 4]. Preoperative diagnosis is generally
neutrophilic infiltration. Three months after surgery, he tricky as their abdominal exam, physical signs, lab results,
was completely asymptomatic and is doing well. and imaging are not always helpful [3]. Symptoms are
usually non-specific and include sudden onset epigastric
or periumbilical pain, tenderness, or even mass in the
inguinal region, mimicking a hernia [1, 4, 5]. Computed
tomography (CT) can aid in the diagnosis; however, since
appendicitis and inguinal hernias are usually diagnosed
clinically, it is rarely ordered on a regular basis and only
use to rule out a more severe pathology [2, 6].
In our case, the patient presented with acute abdominal
pain, and since the pain persisted, laparoscopic surgery was
decided. Most cases are rarely diagnosed preoperatively,
and many cases are diagnosed during surgery [2, 3]; as it
happened to our patient. The herniated appendix can be
normal, acutely inflamed, or perforated, and its treatment
can be based on the Losanoff and Basson classification [3,
7, 8]. The hernia defect should always be repaired unless
there are severe complications. The use of meshes in a
contaminated environment is usually contraindicated
due to the high risk of infection and should be avoided
when the appendix is compromised [1, 9, 10]. Mortality
from Amyand’s hernia range from 14% to 30%, and
wound infection rates can be as high as 50%, mostly due
to the abdominal sepsis that can happen if the appendix
perforates [3, 11].
There is still no agreement in the literature concerning
the best course of action in treating the appendix in
Figure 1: (A) Cecum covering the right inguinal ring; (B) Amyand’s hernia, while there are many reviews which
Appendix within the hernia sac. argue that appendectomy should only be performed if

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Edorium J Surg 2020;7:100049S05AA2020. Ayala et al.  3
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the appendix is inflamed, others support appendectomy 10. Mebis W, Hoste P, Jager T. Amyand’s hernia. J Belg
to avoid future complications. Nonetheless, the decision Soc Radiol 2018;102(1):8.
to remove the appendix will remain on the surgeon [1, 4, 11. Nieto Morales ML, El Khatib Ghzal Y, Santana
6, 12]. Medina E. Amyand hernia. [Article in Spanish]. Cir
Esp 2019;97(7):408.
As the appendix in our patient was found within the
12. Maternini M, Gabrielli F, Pecora N, Riggio V, Chiarelli
hernia sac and to prevent an appendectomy later, it M, Guttadauro A. Amyand hernia in an elderly patient.
was removed without complications despite its normal Ann Ital Chir 2018;7:S2239253X18028475.
appearance. Although open approaches have been
considered the usual treatment of Amyand’s hernias, the *********
laparoscopic approach has proved useful when treating
inguinal hernias [5, 6]. In 1999, Vermillion et al. were Author Contributions
the first surgeons to prove that laparoscopy can be useful
in Amyand’s hernias, as it can help identify unexpected Andres V Ayala – Conception of the work, Design of the
pathologies in an emergency setting. It can provide a view work, Acquisition of data, Analysis of data, Interpretation
of the hernia contents, successfully reduce the hernia, of data, Drafting the work, Revising the work critically
and perform a mesh repair if needed [4, 7–9]. for important intellectual content, Final approval of the
version to be published, Agree to be accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
CONCLUSION
appropriately investigated and resolved
Amyand’s hernia is an extremely rare presentation of Macarena Dávalos – Conception of the work, Design of the
an inguinal hernia. Due to its rare presentations and low work, Acquisition of data, Analysis of data, Interpretation
incidence, it can easily be missed, leading to troublesome of data, Drafting the work, Revising the work critically
complications. High clinical awareness is necessary to for important intellectual content, Final approval of the
provide prompt decisions and accurately treat this rare version to be published, Agree to be accountable for all
and unexpected pathology. aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved
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aspects of the work in ensuring that questions related Data Availability

to the accuracy or integrity of any part of the work are All relevant data are within the paper and its Supporting
appropriately investigated and resolved Information files.

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Conflict of Interest
Authors declare no conflict of interest.

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