Dear sir,
I read with great interest the preprint article by Agrawal et al.,[1] titled “Inguinal herniotomy in children: Retrospective three decades experience”. Med J DY Patil Vidyapeeth [Epub ahead of print, cited March 18, 2022]. In the above retrospective manuscript, authors also reported Amyand’s hernia in seven (0.09%) children.[1] I’m presenting a case of right-sided incarcerated Amyand’s hernia with cecal perforation in an 18-month-old boy. He was admitted with a history of non-reducible swelling at the right side of his inguinoscrotal area for two days. He also had clinical features (abdominal pain, distention, and vomiting) suggestive of intestinal obstruction for one day. He had reducible swelling over the right side of his inguinoscrotal area a few weeks after birth. Clinical examination revealed a right-sided incarcerated inguinal hernia with features also suggestive of intestinal obstruction. An ultrasonographic evaluation revealed a right-sided incarcerated inguinal hernia [Figure 1a]. His abdominal X-ray also showed some areas of calcification, and most of them were in the lower abdomen/pelvic area [Figure 1b]. After appropriate resuscitation right-sided inguinal exploration was done under general anesthesia [Figure 2a]. Contents of the hernia sac were the appendix, pus, some mud-like materials/particles, and part of the cecum [Figures 2b-2d]. On further exploration of the scrotal area, pus and mud-like particles were present. The right side of the pelvic cavity also contained some particles of mud-like materials, and 50 ml of thick pus was also drained out. Peritoneal toileting, inguinal sac, and other contaminated parts were irrigated and cleaned with normal saline. His cecal perforation was closed in two layers with vicryl 3/0. His appendix was not involved in the disease process, and an appendicectomy was not done. A formal inguinal herniotomy was done, and his inguinal wound was closed in layers with peritoneal and scrotal drains. His postoperative period was uneventful. His parents were counselled to take care of the boy’s compulsive eating disorder/Pica. He is doing well in the follow-up period.
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Figure 1: (a) Right inguinal ultrasonography showing incarcerated inguinal hernia, (b) X-ray of the abdomen showing calcification more on the lower abdomen and pelvic area
Figure 2: (a-d): Peroperative photographs showing (a) right incarcerated inguinal hernia and inguinal skin incision, (b) Appendix as a content of the hernia sac, (c) Mud-like contents in the hernia sac as a contents, (d) Perforated cecum (margins freshened) as a content of the hernia sac
Inguinal herniotomy is one of the most frequently performed surgical procedures in the pediatric age group.[1,2] Inguinal hernias are more common on the right side and more frequent in boys.[1,2] Herniotomies in infants and children can be performed either by doing open surgical techniques (most frequently) or by laparoscopic techniques.[1,2] Incarceration is a known complication of inguinal hernias in children, is more frequent during infancy, and is reported in approximately 10% of the cases.[3] Amyand’s hernia is a clinical condition when a vermiform appendix is present in the inguinal hernia sac. It was reported first by Claudius Amyand, a Serjeant Surgeon to King George II of England.[4] The incidence of Amyand’s hernia is approximately 1% in children, and is more frequent in boys.[5] Because of the anatomical location of the appendix, it occurs most frequently on the right side.[5] Amyand’s hernia cases clinically present with symptoms and signs of obstructed/incarcerated inguinal hernia as inguinal or inguinoscrotal swelling.[1,5] The appendix may be inflamed, perforated, or uninflamed in Amyand’s hernia.[1,5] In Amyand’s hernia, the cecum and the appendix as a content of the inguinal hernia sac have been documented, but perforation of the cecum is very rare.[1,6] In general, the management of Amyand’s hernia in children depends upon the condition of the appendix found in the hernia sac during the operative procedure. An inflamed or perforated appendix evidenced during the inguinal exploration requires an appendicectomy.[5] Formal appendicectomy is not always required/advisable for an uninflamed/normal appendix evidenced in the hernia sac, in children.[5,7]
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Consent for publication of clinical/radiological photographs obtained from parents.
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Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Agrawal L, Gupta R, Sharma SB. Inguinal herniotomy in children: Retrospective three decades experience. Med J DY Patil Vidyapeeth. Available from:
https://www.mjdrdypv.org/preprintarticle.asp?id=337800. [Last accessed on 2022 Mar 18].
2. Kantor N, Travis N, Wayne C, Nasr A. Laparoscopic versus open inguinal hernia repair in children:Which is the true gold-standard?A systematic review and meta-analysis. Pediatr Surg Int 2019;35:1013–26.
3. Olesen CS, Mortensen LQ, Öberg S, Rosenberg J. Risk of incarceration in children with inguinal hernia:A systematic review. Hernia 2019;23:245–54.
4. Claudius A. Of an inguinal rupture, with a pin in the appendix caeci, incrusted with stone;and some observations on wounds in the guts. Phil Trans R Soc London 1735;39:329–42.
5. Tartar T, Sarac M, Bakal U, Akdeniz I, Kazez A. Amyand's hernia in children:A 20-year experience at a tertiary referral hospital. Ann Med Res 2022;29:41–5.
6. Kaushal-Deep SM, Ahmad R, Lodhi M. Pneumohernios due to perforated cecum in left Amyand's hernia. J Postgrad Med 2018;64:183–5.
7. Almetaher HA, Mansour MA, Arafa MA. Management of Amyand's hernia in children:should appendectomy be mandatory or not?. Ann Pediatr Surg 2020;16:14.
