Left Sided Amyand’s Hernia, A Rare Occurance: A Case Report

Abstract

This is a case report about a 35 year old man admitted with complains of obstructed left sided inguinal hernia. On exploration of the left inguinal canal to our surprise a normal appendix was found in addition to a gangrenous omentum. Resection of the gangrenous omentum was done. Appendectomy was done. This case is reported for its rare occurance as only three such cases of left sided amyand's hernia has been reported so far in literature [4][5][6].Keywords Amyand's hernia . Obstucted inguinal hernia . appendix Case HistoryA 35 year old male patient was admitted with complaints of obstructed left inguinal hernia to the emergency department. The patient was in severe pain and an emergency laparotomy was planned. Basic blood investigations were taken. X-ray of the abdomen showed dilated small intestinal bowel loops. The patient was prepared and shifted to the operation theatre (Fig. 1).Using an inguinoscrotal incision the left inguinal canal was opened. An indirect inguinal hernia with omentum and the small bowel as contents were noted. The fundus of the sac was opened and about 30 ml of dark fliud was suctioned out careful not to soil the wound. The omentum was found to be gangrenous. The gangrenous omentum was excised. The small intestine was found to be normal with normal peristalsis and so the same was preserved. To our surprise we also noted an appendix as one of the contents of the sac. The appendix was about 10 cm in length. The appendix was normal and not gangrenous. An appendicectomy was done to avoid any future diagnostic dilemma. Since this was a case of obstructed inguinal hernia only a herniorraphy was done. The patient recovered well. An ultrasound of the abdomen was done and it showed non-rotation of the intestines, one of the causes of a left sided appendix. DisscusionAmyand is credited with the first appendicectomy in 1736, when he operated on a boy with an enterocutaneous fistula within an inguinal hernia [1]. On exploration of the hernia sac, he discovered the appendix, which had been perforated by a pin resulting in a fecal fistula. As a result of his original description, an inguinal hernia containing the appendix carries Amyand's eponym to this day [2].There are four conditions that can result in a left-sided appendix. In order of frequency, they are: (1) situs inversus viscerum, (2) nonrotation of the intestines, (3) "wandering" cecum with a long mesentery, and (4) an excessively long appendix crossing the midline. Nisolle et al.[3] described a case of left-sided appendicitis in which the extremity of a dilated right appendix was located in the left lower quadrant (LLQ) along the lateral pelvic wall.The occurrence of herniated appendices is mostly reported in a right inguinal hernial sac, probably as a

Amyand’s hernia: “Jack in the box” - A Case report with a review of literature

“…The appendix can be found in Umbilical [A] [B] hernias, femoral hernia, obturator hernias and even incisional hernias [8]. The incidence of appendicitis in an inguinal hernia is reported to be 0.1% [9,10]. It has been postulated that in an Amyand's hernia anatomically the appendix is predisposed relatively superficial in the groin and repeated abdominal muscle contractions during activity constrict the deep hernial orifice thereby inducing ischemia of the appendix, and then appendicitis, repeated contractions also induce incarceration by repeated inflammation and fibrosis.…”

Acute appendicitis complicating Amyand’s hernia: imaging features and literature review

“…Less than 10 cases of left-sided Amyand's hernia have been reported in the literature; these can occur in patients with situs inversus, intestinal malrotation, or a mobile caecum. [5][6][7][8][9] Appendicitis more frequently occurs in Amyand's hernia than in appendix at normal position. The superficial location of the appendix within the inguinal sac can possibly make it more vulnerable to trauma and secondary inflammation.…”

“…1 Other intraabdominal structures such as the caecum, urinary bladder, and omentum can accompany the appendix and herniate into the hernial sac. 6,7 The diagnosis of Amyand's hernia is rarely made clinically. Most often it is mistaken as an irreducible inguinal hernia.…”

A Rare Presentation of Maydl’s Hernia

“…For type 4, where acute appendicitis is associated with a related or unrelated pathology, the management is as for types 2 and 3 hernias but the second pathology should be investigated and treated appropriately. Left-sided Amyand's hernia is very rare and may be associated with situs inversus, malrotation, a mobile caecum, and an excessively long appendix [ 8 ]. Appendicectomies for left-sided hernias should be a routine irrespective of being inflamed or not.…”

“…This would avoid future doubt if appendicitis occurred [ 9 ]. The use of prosthetic mesh in the repair is normally contraindicated in inflammation and infection [ 6 , 8 ]. In this case, where there was no strangulation nor resection anastomosis of the gut, a mesh hernioplasty would have been most appropriate.…”