Amyand's Hernia as a Random Finding in Acute Abdominal Pain and the Role of Thorough Investigation: a Case Report

Objective:Amyand's hernia is a rare clinical entity, in which the sac of an inguinal hernia contains the appendix. Its incidence is less than 1% of all inguinal hernia cases. Clinical presentation is not specific and can mislead clinical suspicion towards inguinal hernia incarceration. Different classifications have been proposed, with significant importance for the surgical management plan. The main factors to take into consideration include hernia sac content and macroscopic appearance of the appendix, intra-abdominal inflammation, the possibility of hernia recurrence, and patient's general situation and comorbidities. Materials and methods: A 60-year-old male patient with previous history of tension-free right inguinal hernia repair with mesh and cholelithiasis presented to the Emergency Department complaining of acute abdominal pain localized at the right lumbar and right iliac region and a right groin easily reducible mass. The patient had an abdominal CT performed 48 hours ago that revealed cholelithiasis and a recurrent right inguinal hernia containing the appendix. Because of the consistent pain in the right abdomen despite the easily reducible hernia, a high suspicion of a coexisting pathology was raised and a new abdominal CT scan with intravenous and per os contrast agent was ordered. The latter showed an Amyand's hernia and cholelithiasis, but also detected lithiasis of the right ureter with upstream dilatation as the main cause of abdominal pain. Results:The patient was subsequently treated with ureteral stent placement and the following day laparoscopic hernia repair with a transabdominal preperitoneal (TAPP) approach and cholecystectomy were performed. The patient was discharged from hospital on the second postoperative day without complications. Conclusion:Surgeons should be aware of different types of Amyand's hernia and have to include this entity in the differential diagnosis of right iliac fossa abdominal pain combined with a groin mass to avoid intraoperative complications and suboptimal management. It is equally important, though, to exclude other causes of abdominal pain. This case report reviews a rare entity of right inguinal hernia recurrence presenting as Amyand's hernia during the investigation of right abdominal and iliac fossa pain, that was finally attributed to ureteric colic. Special attention should be given to the thorough investigation of abdominal pain causes.