Review
Amyand's hernia: a review

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Abstract

Background

The presence of a vermiform appendix in an inguinal hernia sac is known as Amyand's hernia. The aim of this systematic review was to gather information concerning its prevalence, clinical image, diagnosis, and treatment.

Data Sources

The MEDLINE database was thoroughly searched using the keyword “Amyand's hernia.” Additional articles were gathered and evaluated.

Conclusions

The true prevalence of Amyand's hernia seems lower than classically described. Its usual clinical image is identical to that of an incarcerated hernia, and thus it is almost impossible to diagnose preoperatively, although ultrasound and computed tomography can help. Treatment includes hernioplasty with or without appendectomy and/or mesh repair depending on the vermiform appendix's inflammation status, the patient's general condition, and other factors. Amyand's hernia generally has a good prognosis, although serious complications have been described. Surgeons should be prepared if they encounter Amyand's hernia because appropriate treatment ensures hernia repair without complications and with avoidance of recurrence.

Section snippets

History

The existence of a vermiform appendix in an inguinal hernia was first described by Claudius Amyand (1660 to 1740), the eponym of Amyand's hernia. The name “Amyand's hernia” is used irrespective of the vermiform appendix's situation (normal, inflamed, perforated, or gangrenous). Amyand was a French refugee in England, a military surgeon and sergeant and surgeon to Kings George I and George II. He was a distinguished surgeon, a fellow of the Royal Society, first principal surgeon to the

Prevalence and characteristics

Amyand's hernia is classically described to account for 1% of inguinal hernias and .1% of cases of appendicitis.2, 5, 16 These numbers are based on older research. The rarity of this situation does not allow easy calculation of its true prevalence. Studying some of the largest series described in the literature (Table 1), it seems that the true prevalence is somewhat smaller, between .4% and .6%, while the prevalence of appendicitis in an Amyand's hernia seems in fact to be .1%. This assumption

Clinical signs and symptoms

The clinical image of Amyand's hernia is that of an inguinal hernia and strongly depends on the situation of the vermiform appendix. Its usual appearance is that of a tender inguinal or inguinoscrotal lump. This is clinically indistinguishable from an incarcerated or strangulated inguinal hernia, so that a correct preoperative diagnosis is rarely established.2, 3, 5, 6 The usual duration of pain before admission to the hospital can be 24 hours6 in adults and 2 to 3 days in children.7 It has

Imaging and preoperative diagnosis

Preoperative diagnosis of Amyand's hernia, although almost impossible clinically, is feasible with ultrasound and CT.27 Akfirat et al11 were the first to report ultrasound diagnosis, while Luchs et al12 were the first to diagnose Amyand's hernia on CT. The ultrasound image is that of a blind-ended tubular structure with thickened walls in connection with the cecum inside the hernia sac.52, 53 CT allows direct visualization of the appendix inside the inguinal canal. Even if this is not possible,

Pathophysiology

With respect to the pathophysiology of Amyand's hernia, there are 2 cardinal questions: first, whether the entrance of the appendix to the inguinal sac is an accidental event and, second, whether appendicitis is related to the hernia or just a coincidence.

Concerning the first question, some authors have reported a fibrous connection between the vermiform appendix and testis.1, 29, 61 That, in combination with a patent vaginal process, could lead to the vermiform appendix's guidance and passage

Treatment

Classical treatment of Amyand's hernia includes appendectomy, drainage of abscesses if existent, reduction of hernia, and hernioplasty through the same incision.1, 2, 5 In cases of inflammation, dissemination and peritonitis or cecum incarceration and ischemic right hemicolectomy might be necessary.80, 81 The first laparoscopic repair without mesh of an Amyand's hernia was performed in 1999 by Vermillion et al,82 and the first preperitoneal repair with mesh by Saggar et al83 in 2004. However,

Conclusions

Amyand's hernia is a rare situation. Although it has caused some concern in the past, recent reports show that if treated properly, it does not add morbidity or mortality beyond that of a typical inguinal hernia. Surgeons should examine carefully the vermiform appendix before proceeding with appendectomy and estimate the necessity of mesh repair depending on the vermiform appendix's situation, characteristics of the hernia, and the patient's demographics and special characteristics. In doubtful

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    The authors declare no conflicts of interest.

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