A clinical case of successful treatment of acute phlegmonous appendicitis incarcerated in a hernial sac (Amyand’s hernia)

Abstract

Atypical localization of the vermiform appendix (VA) in acute appendicitis can lead to diagnostic and tactical errors in emergency abdominal surgery. The rarest and most atypical localization of the VA is within the hernial sac. This type of hernia is defined as Amyand’s hernia. The optimal scope of surgical intervention and access method (laparoscopic or open) for Amyand’s hernia have not been definitively determined. Questions remain regarding the necessity of removing an unaffected vermiform appendix, the approach to hernioplasty in destructive appendicitis, and the feasibility of using a mesh implant for hernioplasty. In cases of a sliding hernia, the destruction of the hernial sac can lead to difficulties with suturing the peritoneum, assessing the state of the strangulated testicle in men, and performing an orchidectomy. Therefore, it is imperative to establish an algorithm for the evaluation and surgical management of patients with strangulated inguinal hernias.

Objective —  present a clinical case of successful treatment of Amyand’s hernia with acute phlegmonous appendicitis incarcerated in a strangulated inguinal hernial sac and reactive orchoepididymitis, focusing on the selection of medical and diagnostic strategies to reduce the risk of complications.

The clinical case illustrates the effective management of a patient who presented with acute phlegmonous appendicitis and purulent orchoepididymitis. These abnormalities were found to be atypically localised within the sac of a strangulated right‑sided inguinal hernia, known as Amyand’s hernia. The necessary surgical procedures included an appendectomy and an orchidectomy.

Conclusions. Inflammation of the vermiform appendix in Amyand’s hernia can lead to various unpredictable purulent complications, such as acute typhlitis, purulent peritonitis, necrotizing orchoepididymitis, and Fournier’s phlegmon, necessitating extensive surgical intervention. The collective global and personal experience in treating Amyand’s hernia suggests the possibility of establishing standardised protocols for diagnosing and selecting a surgical intervention technique.