JSSN 2011; 14 (1) 22-23

Case report

Amyand’s Hernia in a Toddler : A Case Report

Khakural P1, Dahal GR2, Pokharel RP3
1
Surgery Resident,2Assisstant Professor,3Associate Professor.Paediatric Surgery Unit,Department of Surgery,TUTH,
Maharajgunj, Kathmandu.
Correspondence to: Prabhat Khakural, Department of Surgery, TUTH, P.O Box-3578, Maharajgunj, Kathmandu
Email-pkhakural@yahoo.com

Abstract
Inguinal hernia containing an appendix is a rare presentation in paediatric age group.We report one
of such rare hernias in a two year old male child who had presented with signs and symptoms of an
irreducible right inguinal hernia.The diagnosis of Amyand’s hernia was made
intraoperatively.Appendectomy and herniotomy were done in the same setting.The postoperative
course was uneventful.We report the case owing to its rarity.
Keywords: Amyand’s hernia, appendectomy ,herniotomy.

Introduction
An inguinal hernia containing an appendix is a rare but a
known entity. In 1735, Claudius Amyand first performed
appendectomy on an 11 year old boy with a perforated
appendix in a hernial sac.1Since then it is referred to as
Amyand’s Hernia(AH).The appendix in the hernial sac can
be inflammed or non inflammed and in the absence of
inflammation,itcan present as an incidental finding.There
has not been any consensus on appendectomy in an
incidental case of AH.Here we report a case of AH in a two
year old boy with a normal appendix.

Case Report
A two year old male child had presented with history of Fig 1.Showing the tip of appendix adherant to hernial sac.
painless right sided scrotal swelling since two months of
age.The swelling had been gradually increasing in
size.There was no history of pain abdomen, nausea, vomiting
or bowel and bladder symptoms.The child didn’t have any
other medical or surgical illness in the past.On examination
the child was a healthy baby with normal development and
nutritional status.There was a right sided reducible inguinal
hernia.He was operated electively with the diagnosis of an
uncomplicated right inguinal hernia.During exploration tip
of appendix was found to be adherant to the hernial
sac.Appendectomy was perfomed after freeing the
appendix and the hernial sac was transfixed. The abdominal
wound was closed in layers. The patient had an uneventful
post operative period.He was started on oral diet on second
post operative day and discharged on the fourth post
operative day.He is doing well in follow up visits. Fig 2. Showing the freed appendix.

JSSN 22 Journal of Society of Surgeons of Nepal

JSSN 2011; 14 (1) 22-23
Fig 3. Showing appendicular stump after appendectomy.
Discussion
AH is defined as the presence of a normal,inflammed or
perforated appendix in an inguinal hernial sac.The incidence
of an inflammed appendix in a hernial sac is 0.1% and that of
a normal appendix is 0.5% to 1%.2 It is a very rare entity in
children,especially in infants and neonate.3AH is mostly
discovered incidentally during an inguinal hernia repair. AH
is commonly reported in the right side,but left sided
Amyand’s hernia has also been reported.4Most of the time
a symptomatic AH presents with features of obstruction
and perforation.It is believed that as soon as the appendix
enters the sac, it’s blood supply is reduced and there is
inflammation and overgrowth of microorganisms.5It is
difficult to diagnose AH preoperatively in a normal appendix.
A preoperative CT scan may be useful in its diagnosis.But
the in case of the complicated or uncomplicated inguinal
hernia radiological investigations are not routinely done..
So, AH is almost always an intraoperative diagnosis.
The treatment of AH depends on factors like the presence
of an inflammed appendix,surgical field contamination
patient’s age and anatomic features of the tissue.6Hernial
appendicitis should be treated with appendectomy through
the herniotomy.7In adults, transherniotomy appendectomy
is performed followed by hernioplasty8 but it has been
recommended that Shouldice’s/Bassini’s herniorrhaphy
should be performed in case of gangrenous
appendicitis.9,10In children,herniotomy is sufficient.
If a normal appendix is found in the hernia, hernia repair
without an appendectomy has been considered a safe
option.9However, manipulation of a normal appendix may
provoke secondary appendicitis11 and hence one may opt
for appendectomy even if the appendix looks healthy.It has
been suggested that if an AH is found incidentally,
appendectomy with herniotomy should be done in order to
avoid the chances of future appendicitis.12In our case, the
tip of the appendix was adherant to the hernial sac.Due to
the excessive tissue handling and tissue dissection,the
vascular supply to the appendix could have been
JSSN
Khakural P ... Amyand’s Hernia in a Toddler
compromised.Hence appendectomy was performed in our
case.
In conclusion, urgent surgery is always a treatment of choice
in case of Amyand’s hernia with features of obstruction,
strangulation or perforation.But in an AH with a normal
appendix, ,herniotomy in children and hernioplasty in adults
may suffice,considering the fact that appendix is gaining
it’s popularity as a spare organ for urological and biliary
sugery.
References
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23 Journal of Society of Surgeons of Nepal