AH is a rare condition, and the diagnosis is usually made incidentally during surgery. With the widespread use of helical computed tomography in current practice, however, several authors have recently reported the ability to diagnose AH by preoperative imaging [
3‐
5]. Surgical treatment of AH requires both appendectomy and hernia repair. The treatment algorithm for AH (Table
1) is generally accepted and recommends different management strategies depending on the severity of the condition of the appendix [
6]. AH of type 3–4 is considered to be complicated by appendicitis and requires surgical treatment with avoidance of mesh. However, the efficacy of combining appendectomy and inguinal hernia repair with or without mesh for other types of AH (type 1–2) remains unclear. Some reports have described appendectomy for inflamed appendices (type 2) combined with mesh inguinal hernia repair [
7‐
12]. Therefore, some authors consider that tension-free inguinal hernia repair with mesh and appendectomy is acceptable for both non-inflamed and inflamed appendices [
3,
8,
10,
12]. In addition, Kose
et al. [
13] proposed using the presence of fibrous connections between the vermiform appendix and the surrounding hernia sac as an indicator for performing appendectomy with mesh inguinal hernia repair. Regarding the treatment of AH, several authors have suggested that laparoscopy can be a safe method for reduction of the appendix without contamination of the inguinal canal and allows the physician to rule out other pathologies [
12,
14]. Mullinax
et al. [
14] published a report of a type 2 AH treated by laparoscopic hernia repair and appendectomy. Only a single report of endoscopic total extraperitoneal management of an intraoperatively diagnosed AH (type 2) has been published [
15].
Table 1
Classification systems for Amyand’s hernia [
6]
Type 1 | Normal appendix | Reduction or appendectomy(depending on age), mesh hemioplasty |
Type 2 | Acute appendicitis localized in the sac | Appendectomy through hernia, endogenous repair |
Type 3 | Acute appendicitis, peritonitis | Appendectomy through laparotomy, endogenous repair |
Type 4 | Acute appendicitis, other abdominal pathology | Appendectomy, diagnostic workup and other procedures as appropriate |
We performed preperitoneal mesh placement and total laparoscopic appendectomy after reducing the appendix by an intraperitoneal approach to treat a preoperatively diagnosed AH. This process was introduced to allow inspection of the hernia canal and confirm the absence of a perforated appendix or peritonitis, as well as observe the degree of fibrous connections between the vermiform appendix and the surrounding hernia sac, which helped to avoid tearing the appendix. The main reasons for selecting TEP repair are that the procedure is not influenced by intra-abdominal conditions and avoids entering the peritoneal cavity, thus protecting the mesh from bacterial contamination.
In conclusion, a laparoscopic mesh inguinal hernia repair combined with laparoscopic appendectomy can be performed for the surgical treatment of AH type 1 and select cases of AH type 2. It may be regarded as a safe technique with minimal morbidity to the patient. In particular, TEP repair of an inguinal hernia with mesh after laparoscopic hernia reduction may help to avoid mesh contamination in patients with an AH.