Left Amyand's hernia in children: Method, management and myth

Abstract

The presence of the appendix within an inguinal hernia is referred to as Amyand's hernia.1 A paediatric surgeon can expect to discover the appendix in one of every 1000 hernia sacs,2 usually at emergency herniotomy. We report an even rarer presentation – left-sided Amyand's hernia discovered unexpectedly at elective surgery in a baby and a toddler. Elective bilateral inguinal herniotomies were performed on a 10-week-old twin boy who had been born at 27 week's gestation. Both hernias were reducible since detection on day 9 of life. The left hernia sac contained small bowel, caecum and appendix. The contents were easily reduced in to the abdomen, and routine inguinal herniotomy was performed. Recovery was uncomplicated. A 13-month-old boy was followed up in clinic having presented at 5 weeks of age with a right communicating hydrocele. The right hydrocoele had resolved, but there was now a reducible right inguinal hernia. He had also developed a tense, non-tender, irreducible left inguino-scrotal swelling thought to be a hydrocoele. A right inguinal herniotomy was subsequently performed in the standard manner. On opening the left inguinal canal to repair the hydrocoele, the inguino-scrotal swelling was actually found to be an incarcerated inguinal hernia. The hernia comprised terminal ileum, caecum and appendix. The bowel was viable and, after further proximal extension of the incision in the peritoneum, was easily reduced in to the abdomen without appendicectomy. The hernia sac was transected distally, preserving the vas and testicular vessels as per routine inguinal herniotomy. Proximally, the edges of the peritoneum were closed with a continuous absorbable suture. An upper gastro-intestinal (GI) contrast study showed normal rotation of the gut. Amyand had a big day on December 6th 1735 at St. George's Hospital, London. Not only did he perform the first appendicectomy, he described finding the appendix, perforated by a pin, in a right inguinal hernia of an 11-year-old boy.3 To unexpectedly find a left Amyand's hernia in two children at elective operation is most unusual. The majority of reported cases of left Amyand's hernia present as emergencies, appendicitis or strangulated hernia, in adults. The largest series of Amyand's hernia in children reports on 30 cases, only three of which were left sided.4 One of the three presented with perforated appendicitis in the hernia, and the other two were detected on axial imaging pre-operatively. We describe the technique of herniotomy in this unusual situation for the first time. By carefully incising the encasing processus vaginalis and extending this incision distally on the spermatic cord and proximally towards the deep inguinal ring, enough exposure was possible to: (i) identify the hernia contents; (ii) inspect the hernia contents for viability; (iii) reduce the hernia to the abdominal cavity; and (iv) repair the hernia by herniotomy. All reports to date suggest that the caecum and appendix herniate through the left inguinal canal because of either high caecal mobility, situs inversus or malrotation of the gut. In one case report, the finding of an appendicitis in the left inguinal canal lead the surgeons to consider malrotation, and a midline laparotomy was performed simultaneously5 – the bowel was rotated normally. Our second patient underwent a post-operative upper GI contrast study which was normal. In the absence of any report of left Amyand's hernia in children or adults associated with situs inversus or malrotation, we suggest that these concerns are unfounded, and certainly, exploratory laparotomy can be avoided. It is generally agreed in all preceding case reports that appendicectomy in Amyand's hernia is not indicated unless it is inflamed or strangulated. However, Johari et al.6 suggest removing a normal appendix when found in the left inguinal canal as this raises the possibility of malrotation and the potential for later atypical presentation with appendicitis. Again, the current authors believe that in the absence of inflammation and any report of associated malrotation with left Amyand's hernia, ‘prophylactic’ appendicectomy is not indicated. Our rare cases allowed us to describe in detail the operative management of left Amyand's hernia in children discovered at elective operation. Rather than repeating old myths, we have outlined the management of these children, specifically advising against prophylactic appendicectomy of a non-inflamed appendix, and the avoidance of unnecessary interventions (laparotomy) or investigations (contrast studies) for malrotation or situs inversus.