Abdi Tesemma¹*, Quenton Wessels², Miheret Adane³, Bekam Debebe¹, Demisu Zenbaba⁴, Girma Beressa⁴

¹Department of Surgery, Madda Walabu University, Goba, Ethiopia

²Hage Geingob Campus: School of Medicine, University of Namibia, Windhoek, Namibia

³School of Health Sciences, Madda Walabu University, Goba, Ethiopia

⁴Public Health, Madda Walabu University, Goba, Ethiopia

*Corresponding Author: Abdi Tesemma, Department of Surgery, Madda Walabu University, Goba, Ethiopia.

Abstract
Background: Hernias are among the oldest sufferings in human beings. Amyand's Hernia, a rare type of inguinal hernia with an incarcerated vermiform appendix, requires a high index of suspicion for preoperative diagnosis as it plays a major role in deciding the appropriate management option.

Case presentation: An 85-year-old an Ethiopian male presented with a complaint of painless right inguinal swelling for 8 years and irreducibility of the swelling and pain over the site of one day duration. On examination, a tense, soft, irreducible and mildly tender right inguinoscrotal mass which measured 5x10 cm was identified. An intra operatively inflamed appendix was found in the hernia sac; appendectomy, reduction and tissue repair herniorrhaphy was performed.

Conclusion: We conclude that the ideal management protocol must be individualised in each case, not only considering the criteria of an inflamed appendix or not but also other factors.

Keywords: Amyand's Hernia, inguinal hernia, right-sided, appendectomy, Ethiopia

Introduction
The first successful appendicectomy recorded in history was performed by the French born English surgeon Claude D'Amyand (c. 1680-1740) at George's Hospital, London in 1735 [1,2]. D'Amyand's family were Huguenot refugees and Claude became an English national in 1698 and became known as Claudius Amyand [1]. Amyand performed the procedure on an 11-year-old boy, named Hanvil Anderson, who presented with an inguinal abscess and faecal fistula, and an entrapped vermiform appendix within an inguinal hernia [3, 4]. This historical case was further complicated by the presence of an encrusted pin which was swallowed by the patient, leading to perforation of the hernia sac [3]. Furthermore, the appendicectomy was performed without anaesthesia and the procedure took 30 minutes to conclude [3,4].

Inguinal hernias are the most frequently encountered hernia and typically contain the small intestine or omentum [5]. The presence of other organs such as the vermiform appendix, ovary, fallopian tube, caecum, sigmoid colon, Meckel's diverticulum, or urinary bladder is extremely rare [5]. Amyand Hernia is characterised by either: an inflamed appendix within the hernia sac, a perforated appendix within the hernia, or findings a normal (noninflamed) appendix within the hernia [6]. The incidence of a normal appendix inside an inguinal hernia sac is estimated to be between 0.4% and 0.6%, but the incidence of acute appendicitis in Amyand's hernia actually seems to be 0.1% [6]. Right-sided Amyand's hernia is the most common form but rarer cases of left-sided Amyand's hernias have also been described in literature [2, 6, and 7].

Case Presentation
An 85-year old male Ethiopian farmer, who had a painless reducible right groin swelling for the past eight years, came to Goba Referral Hospital, Bale Zone, South East Ethiopia, with a complaint of irreducibility of the swelling and pain over the site of one day duration.

His clinical examination showed PR 88, T 36.5, BP 130/80 and on abdomen, there was a pear shaped right inguinal swelling of size 5x10 cm, which extended to the base of the scrotum, with healthy looking overlying skin. Gurgling sounds were heard over the mass. Palpation revealed a tense, soft, irreducible and mildly tender right inguinoscrotal mass with both testes palpable and trans-illumination was negative.

Baseline blood investigations were in normal range and abdominopelvic ultrasound showed a right irreducible indirect inguinal hernia containing bowel loops in the hernia sac.

The patient underwent surgery under spinal anaesthesia after written informed consent. A right inguinal incision was made to reveal a right indirect inguinoscrotal hernia with an inflamed appendix (Figure 1) and it also contained the terminal ileum and omentum. The contents of the sac were reduced, appendectomy and Modified Bassini's approach  tissue  repair  was  performed.  Postoperatively,  broad spectrum antibiotics and analgesic were started and the patient had a smooth recovery and was on follow up for the last eighteen months with good outcome.

Figure 1: Shows inflamed appendix in the right inguinal sac (black arrow), opened right inguinal sac (green arrow) and right scrotum (white arrow).

Discussion
In the current case, the authors described right-sided Amyand's hernia, even though it was first described in 1735, the eponym was first used by Creesein 1953 [8]. Today, the Amyand's hernia presentation, diagnosis and management remain a challenge due to the rarity of such cases and the wide variety of its presentation [8].

The true prevalence of a normal appendix being found inside an inguinal hernia sac is estimated to be between 0.4% and 0.6%, however like our case presentation; the prevalence of an acute appendicitis in Amyand's hernia actually seems be 0.1% (Errabi, Cisse et al. 2023). The most common form of presentation of the cases of Amyand's hernia is right-sided irreducible inguinal hernia which is sometimes painful, cases of left-sided Amyand's hernias have also been described in relation with situs inversus, intestinal malrotation, or mobile caecum (Namdev, Sanjay et al. Jun 2020).

Early preoperative diagnosis plays a major role in deciding the management planning of Amyand's hernia. Once the hernia has been diagnosed, its content should be checked carefully and this requiresa high index of suspicion in order to proced in surgical decision making. Ultrasound plays an essential role in diagnosis and will typically show a blind-ended tubular structure inside the hernia sac - the incarcerated appendix. Ultrasound criteria for diagnosing an inflamed appendix are the identification of a blind-ending, non- compressible, non-peristaltic tubular structure measuring more than 6 mm in diameter. On Doppler USG appendiceal wall hyperaemia is a common finding in acute appendicitis. Appendicoliths, which appear as hyper-echoic foci and presence of pericaecal inflammatory changes such as hyper-echoic fat or free fluid considered as suggestive of but not specific for appendicitis and showing the contents of the hernia sac. CT imaging plays a crucial role in preoperative diagnosis and shows a blind ended tubular structure connected to the caecum within the hernia sac (Vehbi, Agirgun et al. 2016).

Management of Amyand's hernia is currently dependent on the algorithm described by Losanoff and Basson (Table 1) depending on the conditions of the appendix (Losanoff and Basson 2008).

Table 1: Losanoff and Basson classification of Amyand’s hernia and their respective management options

The primary management of Amyand’s hernia with a normal appendix is reduction of contents of hernia and repair without appendectomy as this prevents from convertinga clean surgery into a clean-contaminated. Secondary acute inflammation from appendectomycould also increase the risk of recurrence of inguinal hernia (Siddiqui, More et al. July 25th, 2023)

Most authors consider appendectomy indicated only in cases in which the appendix is inflamed. The conflict arises in Type 2 Amyand’s hernias; there is no ground rule whether to use mesh repair or not and whether appendectomy indicated in all cases. In our case which was type II Amyand”s hernia; we performed appendectomy and Modified Bassini tissue repair. Ideal management protocol must be individualised in each case, not only considering the criteria of an inflamed appendix or not, but also other less important factors such as age of the patient, phase of appendicitis, the degree of involvement of the surrounding tissue, the incidents that arise during the intervention, recurrences and comorbidities of each patient (Romero, Pineda et al. 2023).