In the operating room, a lower midline incision was made. Extraperitoneal dissection was performed to separate the peritoneum from the anterior abdominal wall. The left inguinal hernia neck was identified at the internal inguinal ring. The peritoneum was subsequently opened to reduce both the small bowel and colon entering the hernia defect. The hernia contained loops of healthy-appearing small bowel and a markedly dilated cecum (approximately 10 cm in diameter). There were multiple areas of patchy necrosis with punctate leakage of intraluminal contents. The appendix was also identified and found to be normal. A right hemicolectomy with primary anastomosis was performed. The hernia sac was then ligated at the neck and the peritoneum was closed. Flat Vicryl mesh was placed over the left inguinal hernia defect and the abdomen was closed. At a 3-month postoperative evaluation, the patient had no evidence of recurrence.

An Amyand hernia, first described by Claudius Amyand in 1735,¹ is an uncommon inguinal hernia that contains the appendix, which may be perforated, inflamed, or normal. Our patient had a rare case of an Amyand hernia occurring on the left side. In the past, the incidence of Amyand hernias was cited as approximately 1%,² though it may be even less common. Sharma et al³ describe their institution's 15-year experience, in which 18 cases were noted during 14 years. All of these cases were noted on the right. Left-sided Amyand hernias are seen but are even less common.⁴

The presentation of an Amyand hernia can vary and is often that of a strangulated inguinal hernia.⁵ The diagnosis is unlikely to be made preoperatively, though the increasing use of computed tomography has made this more of a possibility.⁶ It is far more frequently an unexpected intraoperative finding. The management of an Amyand hernia is typically dictated by the intraoperative circumstances. If the hernia contains a perforated or gangrenous appendix, proper management involves an appendectomy, much as Amyand himself performed. Although the use of mesh has been reported,⁷ it is generally avoided, as it is associated with increased infectious risks and a greater likelihood of recurrence. In an Amyand hernia with a noninflamed appendix, management is more controversial. Some authors argue that transecting the appendix increases the risk of an otherwise sterile operation.⁸ Avoiding appendectomy can also allow the use of a prosthetic mesh to repair the hernia defect with less concern for future infection.³ Some authors, however, favor incidental appendectomy to decrease the future risk of appendicitis.⁹

Our case describes a left-sided Amyand hernia with a normal-appearing appendix. Although the appendix was not inflamed, the cecum was infarcted and had microperforations, necessitating a resection. The hernia repair was performed with a preperitoneal technique using an absorbable mesh owing to contamination from cecal perforation.

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Submissions The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

AUTHOR INFORMATION

Accepted for Publication: January 13, 2009.

Author Contributions: Study concept and design: Sun, Moazzez, and Mason. Acquisition of data: Sun and Moazzez. Analysis and interpretation of data: Sun, Moazzez, and Mason. Drafting of the manuscript: Sun and Moazzez. Critical revision of the manuscript for important intellectual content: Sun, Moazzez, and Mason. Statistical analysis: Sun. Administrative, technical, and material support: Sun, Moazzez, and Mason. Study supervision: Moazzez and Mason.

Financial Disclosure: None reported.

1. Amyand C. Of an inguinal rupture, with a pin in the appendix caeci, incrusted with stone, and some observations on wounds in the guts. Philos Transact R Soc Lon. 1735;39:329-336. 2. Thomas WEG, Vowles KDJ, Williamson RCN. Appendicitis in external herniae. Ann R Coll Surg Engl. 1982;64(2):121-122. WEB OF SCIENCE | PUBMED 3. Sharma H, Gupta A, Shekhawat NS, Memon B, Memon MA. Amyand's hernia: a report of 18 consecutive patients over a 15-year period. Hernia. 2007;11(1):31-35. FULL TEXT | PUBMED 4. Breitenstein S, Eisenbach C, Wille G, Decurtins M. Incarcerated vermiform appendix in a left-sided inguinal hernia. Hernia. 2005;9(1):100-102. FULL TEXT | PUBMED 5. D’Alia C, Lo Schiavo MG, Tonante A; et al. Amyand's hernia: case report and review of the literature. Hernia. 2003;7(2):89-91. FULL TEXT | PUBMED 6. Ash L, Hatem S, Ramirez GA, Veniero J. Amyand's hernia: a case report of prospective CT diagnosis in the emergency department. Emerg Radiol. 2005;11(4):231-232. FULL TEXT | PUBMED 7. Torino G, Campisi C, Testa A, Baldassarre E, Valenti G. Prosthetic repair of a perforated Amyand's hernia: hazardous or feasible? Hernia. 2007;11(6):551-554. FULL TEXT | PUBMED 8. Hutchinson R. Amyand's hernia. J R Soc Med. 1993;86(2):104-105. WEB OF SCIENCE | PUBMED 9. Ofili OP. Simultaneous appendectomy and inguinal herniorrhaphy could be beneficial. Ethiop Med J. 1991;29(1):37-38. WEB OF SCIENCE | PUBMED

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