Challenges in strategies for Amyand hernia in children: literature review with clinical illustrations

Jalil S., Azhar M., Malkani I., Harb ElKadi T.T., Ali A.E., Wahid F.N.

Amyand's Hernia (AH) is a rare entity described as the presence of the vermiform appendix in an inguinal hernial sac. Though its prevalence is three times more in children than adults, owing to the presence of patent processus vaginalis, its occurrence with acute appendicitis is more uncommon in children, especially in infants. Seldom diagnosed correctly ahead of surgical exploration, it is often clinically diagnosed as an incarcerated inguinal hernia or as a case of acute scrotum. The management of such cases depends upon the per-operative findings. In this series, we report four cases of AH treated at King Saud Medical City Hospital Riyadh between 2018 and 2022. All the four patients were male and three of them were infants. Three patients had right sided hernia, while one had bilateral inguinal hernia. One of the patients was diagnosed with strangulated hernia and upon exploration it was AH with acute appendicitis and appendectomy was done. One child had recurrent, irreducible hernia and upon exploration, found appendix densely adherent to the hernial sac. Another patient had early suppurative inflammation at the tip, while the patient with bilateral hernias had appendix adherent to the right hernial sac. In all our cases appendectomy was performed either due to inflammation or adhesions. There is a rarity of this condition and few cases have been reported in the literature. Such cases need to be reported to keep the surgeons aware of this condition and its different manifestations. Herein, we aim to share our experience of four cases of AH with varied presentations and a literature review.

Hernández-López U.D., Vargas-Buelvas A., Muñoz-Murillo W.J., Muñoz-Murillo K.L., Nuñez-Rojas G., Rahman S.

Congenital hernias occur 70% on the right side, 25% on the left side, and approximately 5% bilaterally. The finding of a congenital Amyand's hernia is of interest, especially in patients who do not present risk factors associated with connective tissue disorders, ascitic conditions, fetal developmental disorders or any condition that increases abdominal pressure.Male patient, 6 months old, was brought to the pediatric surgery department due to a visible mass in the bilateral inguinal region, which protruded with crying. The parents report that he was a 36-week preterm, low birth weight, monochorionic monoamniotic twin with bilateral congenital inguinal hernia. An open herniorrhaphy was performed, showing a left communicating hydrocele with an indirect left inguinal hernia and right communicating hydrocele with indirect inguinal hernia containing cecal appendix with no signs of inflammation.The most common clinical presentation is the presence of a reducible or irreducible mass, erythema and/or inguino-scrotal edema, irritability manifested by crying and recurrent pain in older infants. This condition may be associated with cryptorchidism, intrauterine structural developmental disorder, and the presence of fistulas. Appendectomy and traditional hernia reduction are the most common surgical approach. The evolution of this condition is favorable with extremely low complication rates.Amyand's hernia in the neonate is a rare presenting condition, which frequently involves nearby structures with risk of inflammation, incarceration and perforation, so repair should be performed early.

Huttinger R.M., Sawyer E.M.

An 8-year-old male presented for evaluation of symptoms consistent with appendicitis. Upon laparoscopy, the patient was found to have appendicitis with a concomitant Amyand hernia. The latter pathology highlights a rare presentation of inguinal hernias in which the vermiform appendix herniates into the inguinal canal. Inguinal hernias are frequently encountered in pediatric populations; however, Amyand hernias have seemingly negligible incidence in all age demographics. These comprise roughly 1% of all diagnosed abdominal hernias. When seen in concurrence with appendicitis, the incidence is 0.13%. Recent literature has sought to classify types of Amyand hernias and criteria described by Losanoff and Basson is an attempt to guide surgical management. Although our management did not coincide with the proposed management above, the patient made a full recovery. In conclusion, Amyand hernias remain a rare entity that can be indistinguishable from routine inguinal hernias on clinical examination and management of Amyand hernia with appendicitis is not well defined.

Elgazar A., Awad A.K., Mandal D., Faddah R.M., Elder Z., Elseidy S.A.

Abstract First operated by Claudius Amyand in 1735. Amyand’s hernia is a rare presentation and accounts for only 1% of all inguinal hernias. Amyand’s hernia is described when the appendix is trapped within an inguinal hernia. In most cases, Amyand’s hernia is an incidental finding intra-operatively due to variable clinical manifestations, and features. Amyand’s hernia has variable theories explaining its pathophysiology besides having multiple proposed surgical approaches either via laparoscopic or open repair and with the latter being in a debate of pro and against mesh repair. We present a case of a sliding Amyand’s hernia in which the vermiform appendix and part of the cecum were adherents to the wall of a right inguinal hernial sac. Amyand’s hernia is a rare form of inguinal hernias and its presentation is widely variable. However, in most cases, it is non-complicated and is found as an incidental intraoperative finding. Many studies debate among different diagnostic and management approaches to serve a better outcome with fewer operative complications.

Abdul Hafiz M.Z., Jon Efendi, Budi Pratama Arnofyan

Amyand’s hernia is rare condition defined as the inclusion of the appendixin an ingunal hernia sac, It is an uncommon and rare condition estimatedto be found in approximately 1 % of hernia. However, in just 0.08 %, thecondition is complicated by an acute appendicitis. It may present as atender inguinal or inguinoscrotal swelling. In patients presenting amyand’shernia with mechanical bowel obstruction, signs of acute appendicitis maynot be initially recognized. This was the case while our patient was insurgery, as signs suggestive of acute appendicitis were discovered and thepatient received appendectomy and herniotomy. Presently, We report a caseof Amyand’s hernia in a 9-month-old male, who presented as a left-sidedcongenital hernia with distended abdominal and pain in the left groin. Heunderwent appendectomy and herniotomy, which revealed that the herniasac containing elongated inflamed appendix appeared with some adhesionsto sac, lying in the inguinal canal.

Manatakis D.K., Tasis N., Antonopoulou M.I., Anagnostopoulos P., Acheimastos V., Papageorgiou D., Fradelos E., Zoulamoglou M., Agalianos C., Tsiaoussis J., Xynos E.

Protrusion of the appendix within an inguinal hernia is termed an Amyand’s hernia. A systematic review of case reports and case series of Amyand’s hernia was performed, with emphasis on surgical decision-making. The English literature (2000–2019) was reviewed, using PubMed and Embase, combining the terms “hernia”, “inguinal”, “appendix”, “appendicitis” and “Amyand”. Overall, 231 studies were included, describing 442 patients. Mean age of patients was 34 ± 32 years (adults 57.5%, children 42.5%). 91% were males, while a left-sided Amyand’s hernia was observed in 9.5%. Of 156 elective hernia repairs, 38.5% underwent appendectomy and 61.5% simple reduction of the appendix. 88% of the adult patients had a mesh repair, without complications. Of 281 acute cases, hernial complications (76%) and acute appendicitis (12%) were the most common preoperative surgical indications. Appendectomy was performed in 79%, more extensive operations in 8% and simple reduction in 13% of cases. A mesh was used in 19% of adult patients following any type of resection and in 81% following reduction of the appendix. Among acute cases, mortality was 1.8% and morbidity 9.2%. Surgical site infections were observed in 3.6%, all of which in patients without mesh implantation. In elective Amyand’s hernia cases, appendectomy may be considered in certain patients, provided faecal spillage is avoided, to prevent mesh infection. In cases of appendicitis, prosthetic mesh may be used, if the surgical field is relatively clean, whereas endogenous tissue repairs are preferred in cases of heavy contamination.

Tartar T., Saraç M., Bakal Ü., Onur M.R., Kazez A.

Gaffley M., Pranikoff T., Shetty A.

Acute appendicitis is a common disease afflicting the pediatric population. There are textbook presentations of periumbilical abdominal pain that migrates to the right lower quadrant with following nausea, possible diarrhea, anorexia, fever and eventual sepsis. The abnormal presentations are difficult to sort at times and varying presentations have been noted. The differential should remain broad in evaluating patients as our case illustrates.

Almetaher H.A., Mansour M.A., Arafa M.A.

Amyand’s hernia (AH) is defined as protrusion of the vermiform appendix within the sac of the inguinal hernia and usually misdiagnosed as obstructed hernia. It is more common in pediatric patients but there are controversies about dealing with the normally looking appendix in AH. The aim of this study is to present our experience in the management of AH and highlights the difference in dealing with normally looking appendix between pediatric and adult patients. Patients’ demographics, intraoperative, and postoperative outcome were reported and analyzed. This is a retrospective analysis of 12 pediatric patients aged between 15 days and 5 years presented with AH and operated in tertiary referral hospital over 10 years. This study included 10 males and 2 females. The median age at the operation was 7 months. Eleven patients were operated using conventional technique, and only one patient was operated using laparoscopy. In 11 patients, the appendix was looking normal and was reduced without appendectomy, and the hernia was repaired. Appendectomy was done in one patient presented with AH containing inflamed appendix. The postoperative course was uneventful in all cases. There is a difference in the management of pediatric and adult patients presenting with AH, and appendectomy is not mandatory in normally looking appendix in pediatric patients.

Omran A., Gawrieh B.S., Abdo A., Ali Deeb M., Khalil M.A., Shater W.

Abstract The presence of vermiform appendix in an inguinal hernia sac is known as Amyand’s hernia. This research paper examines the case of a 28-day-old Syrian male presented with a history of an infected right-sided hydrocele from the age of 14 days. Upon admission, ultrasonography was reported as a right testicular torsion. Accordingly, emergency surgical exploration was performed, and by exposing the spermatic cord fascia, 7 mL of pus was drained, revealing the cecum and perforated appendix lying beside the right testis, which showed evidence of ischemia and bluish discoloration.

Kauffman J.D., O'Brien M., Snyder C.W., Rottgers S.A., Rideout D.A., Chandler N.M.

Necrotizing fasciitis is a rare complication of appendicitis in children and is associated with significant morbidity and mortality. We present the case of a 16-year-old male who presented with perforated appendicitis and subsequently developed necrotizing fasciitis of the abdominal wall and perineum. His seven-week hospital course was notable for 16 trips to the operating room, which culminated in staged, complex abdominal wall repair. Ultimately he was discharged home in good condition. The case is remarkable for the extent of soft tissue damage and complexity of repair precipitated by an uncommon complication of a common pediatric disease.

Kaushal-Deep S., Ahmad R., Lodhi M.

Shanmugam V., Dhanasekarapandian V., Jagannathan M.

Yodoshi T., Hurt T.L.

A 10-day-old boy, born at 36 weeks’ gestation, was brought to our emergency department (ED) with irritability. He was able to suck as usual, but his temperature was 37.9°C and his right inguinal region was slightly erythematous. Laboratory data showed leucocytosis with a total leucocyte count of 23×109/L (neutrophils 72.5%), but a low C reactive protein (

Mebis W., Hoste P., Jager T.

Suliman A., Elfaki H., Hussein S.

Amyand's hernia (AH) is an extremely rare type of inguinal hernia where the vermiform appendix is present within the inguinal hernia sac. This report documents the first known instance of AH in Sudan, highlighting its unprecedented occurrence in this region.