LAUSR

A 70-year-old gentleman presented with a 1-day history of increasing right groin lump and pain. This is in the context of a recurrent right inguinal hernias and prior open repair awaiting repeat repair electively. He denied any symptoms of obstruction or infection. Other relevant medical history was hypertension, coronary artery bypass grafting on aspirin, open radical prostatectomy and artificial urethral sphincter for urinary incontinence. On examination, he was afebrile and his vital signs were normal. There was a lump in the right inguinal region consistent with an irreducible hernia. It was tender to palpation without overlying skin changes. Abdominal examination was otherwise benign. Initial blood investigations demonstrated mild elevation in C-reactive protein (38 mg/L) with normal white cell count (7.6 × 10/L), neutrophils (5.7 × 10/L) and creatinine (74 μmol/L). Computed tomography of the abdomen was subsequently performed to characterize the hernia. The right inguinal hernia sac contained a distended vermiform appendix (10 mm) with signs of inflammation, fat stranding and free fluid (Fig. 1a). A 7-mm appendicolith was noted at the tip of the appendix (Fig. 1b). These appearances were in keeping with Amyand’s hernia complicated by acute appendicitis. Laparoscopy confirmed herniation of the appendix via the deep inguinal ring (Fig. 2). The caecum was not involved. The artificial urethral sphincter reservoir was encountered intraperitoneally with surrounding omental adhesions. Attempted reduction of the herniated appendix resulted in avulsion. The proximal end of the appendix was removed laparoscopically. The remaining distal end of the appendix was retrieved via an open right inguinal approach. The tip was acutely inflamed and densely adherent within the sac. Ultimately, the hernia sac was ligated and the inguinal canal was primarily reconstituted in layers with sutures. His post-operative recovery was uneventful and he was discharged following 5 days of intravenous antibiotic. The final histopathology result confirmed an acute inflammation of the appendix without evidence of malignancy. Amyand’s hernia is defined as an inguinal hernia that contains the vermiform appendix. The name was a tribute to Claudius Amyand, a surgeon who first discovered and treated the condition in 1735. It is a rare presentation with an incidence of 0.19–1.7%. Presence of appendicitis in an Amyand’s hernia is far less common, reported to be at 0.1% of cases. It is more prevalent in male and demonstrates a bimodal age distribution with a peak incidence in neonates and in patients aged above 70 years. Many theorize that the herniation of the appendix via a patent vaginal process increases the risk of trauma and compromised blood supply, leading to ischaemia and inflammation. The clinical manifestation of an Amyand’s hernia is similar to that of an inguinal hernia. Acute inflammation of the appendix usually results in a tender inguinal or inguinoscrotal lump, mimicking an incarcerated or strangulated inguinal hernia. Interestingly, patients with severe appendicitis, for example perforation, may have diminished septic response because the neck of the hernia will usually contain and limit the spread of infection into the abdominal