A 70-Year-Old Man With Deteriorating Mental Status and Pain

Gamal A. Bebars, MD, FRCS; Evelyn P. Bebars, MD, FPCR

Disclosures

October 23, 2018

Amyand hernias can be classified into 4 types: type I, with a normal appendix; type II, with an acute appendicitis localized in the hernial sac; type III, with localized peritonitis; and type IV, with generalized peritonitis. The most common presentation of Amyand hernia with appendicitis is a painful irreducible inguinal or inguinoscrotal swelling. Patients with irreducible or incarcerated Amyand hernias present with clinical manifestations of bowel obstruction or perforation.[3] Published articles regarding preoperative diagnosis of Amyand hernia by ultrasonography or CT scanning are extremely rare, and the condition is almost always discovered intraoperatively.[4,5]

Reported conditions in patients presenting with incarcerated Amyand hernias include mucocele of the appendix associated with coexisting colon cancer, fecaliths of the appendix with coexisting colonic diverticulitis, adenocarcinoma of the appendix, and inguinal appendicocele with pseudomyxoma peritonei. A high index of suspicion accompanied by CT scans can avoid delays in management by helping the detection of any coexisting conditions and the planning of the most appropriate procedure, thereby improving patient outcomes.[2,4,5] Although helpful, obtaining CT scans must not delay surgical consultation or intervention in critically ill patients with a surgical abdomen. The most important aspect of surgical intervention in Amyand hernia is to limit any septic spread that can result from perforation of the appendix. Once the septic process involves the peritoneum, it becomes more difficult to manage and is associated with increased mortality.

The surgical management of Amyand hernia should be decided on a case-by-case basis according to the type of hernia and the patient's condition. Options include reduction of the appendix and mesh hernioplasty for type I, and appendectomy followed by endogenous repair without mesh for type II. The management of types III and IV Amyand hernia require more complex procedures, such as exploratory laparotomy, orchiectomy, right hemicolectomy, and debridement of any necrotic bowel. Hernioplasty is contraindicated and should be deferred if the patient's condition is poor or life expectancy is limited.[2,3]

When considering appendectomy, the surgeon must be mindful of the ease of its reduction and the presence or absence of appendicitis, in addition to the type of Amyand hernia. If significant trauma occurs to the appendix during a difficult reduction, an appendectomy is indicated because traumatic injury to the appendix increases the risk for postoperative appendicitis.[6] If appendicitis or incipient necrosis of the appendix are present, a transherniotomy appendectomy should be performed.[7]

Mullinax and colleagues described the management of an Amyand hernia through laparoscopic techniques in an elderly woman. Preoperative CT scanning to rule out possible incarcerated femoral hernia or appendicitis demonstrated distal appendiceal incarceration in a right inguinal hernia. Concomitant laparoscopic inguinal hernia repair and appendectomy were successfully performed, and the authors recommend that this approach be considered when evaluating surgical options for patients suffering from Amyand hernia.[8] In another report, Cankorkmaz L and colleagues described their 8-year institutional experience managing cases of Amyand hernia in the pediatric population, in which they found the status of the inflamed appendix may be used to determine the type of hernial repair and the operative approach in these patients.[9] Although the investigators did not recommend incidental appendectomy in children with an inflamed appendix, appendectomy via the hernia sac and hernia repair were successful.

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