BSN 3-3

NCM II Prelim: Assignment 2

Case Report of Inguinal Hernia: Amyand’s Hernia

Case Presentation
An 87 years old male patient presented in our surgical emergency
department complaining from a 2 week protruding bulge accompanied with
pain in the right groin. The patient denied any vomiting or nausea. Regarding
the history of the patient, he had no problems with defecation or micturition.
Clinical examination revealed a clear right sided inguinal hernia. The mass
was tender by palpation. The leucocyte count was 14 × 109/L.

Introduction
Inguinal hernia is one of the most common surgical problems, often
posing technical challenges even to expert surgeons. Amyand’s hernia (AH)
is an inguinal hernia whose sac contains the vermiform appendix.
Amyand’s hernia cases have been recorded in every age, from neonates
to elderly. The incidence of Amyand’s hernia is 1%. The association of
Amyand’s hernia with appendicitis is even more uncommon, having an
incidence of 0,1%. The majority of cases are right-sided,
The presence of the appendix within the hernial sac makes it more
likely to develop adhesions between serous membranes and hernial sac, with
subsequent irreducibility of the hernia, which would increase the risk of
appendix inflammation. Contractions of the abdominal muscles can cause
intermittent compression of the appendix, which leads to ischemia of the
appendix, infection and severe inflammation. Inflammatory swelling of the
appendix can give rise to a vicious circle: it makes Amyand’s hernia no
longer reducible, thus exacerbating the swelling caused by venous stasis and
bringing about a reduced microcirculatory blood flow in the appendix wall,
with subsequent bacterial proliferation and translocation.
 Diagnosis is, in the majority of cases, intrasurgical. A clinical diagnosis
is made difficult by the fact that in asymptomatic cases, there is no indication
that could lead to think of such positioning of the appendix.

Main Topic
Most patients are asymptomatic, and that is why they are mostly found
incidentally in appendectomy specimens. Clinical manifestations often mimic
those of an incarcerated right inguinal hernia, rendering the correct
preoperative diagnosis very difficult.
Appendectomy and hernia repair without prosthesis implant are the
most suggested procedure as be performed, due to the contamination of the
operating field where appendix surgery is performed.
The patient complained of pain in the inguinal area upon arrival to the
emergency department. The nurse must be well aware of the level of pain of
the patient to be able to know the appropriate measure to manage the
discomfort. The nursing diagnosis for pain will be: Acute Pain related to
hernia and associated tissue stretching or incarceration as evidenced by the
patient’s report of pain or discomfort. Assess the patient’s pain level using a
pain scale and ask about the location, intensity, and quality of the pain.
Provide comfort measures such as applying cold packs or providing
positioning support to alleviate pain and reduce inflammation. Educate the
patient about proper lifting techniques and strategies to avoid activities that
may exacerbate pain or cause further hernia complications. Encourage the
patient to report any changes in pain intensity or quality, as this may indicate
hernia incarceration or strangulation.

Conclusion
The major complications of Amyand’s hernia include perforation of the
appendix, necrotizing fasciitis of the anterior abdominal wall and secondary
intestinal perforation.
Amyand's hernia is a rare presentation of inguinal hernias. In the
clinical setting of an incarcerated complicated or strangulated inguinal hernia,
the initial approach should consider imaging studies; USG or CT can guide
the surgical plan, and enables the possibility of identifying involved
intra-abdominal organs. Literature review recommends reducing the hernia
content and perform no tension hernia repair, In the cases where an inflamed,
suppurative or perforated appendicitis were encountered, no prosthetics
material should be used because of the increased risk of surgical site
infection.in case of clinical suspicion of Amyand hernia is diagnostic
laparoscopy which is useful approach in all forms of incarcerated hernias to
assess contents and avoid unnecessary laparotomy
A malignancy of the appendix should always be in the differential
diagnosis of a right inguinal mass, in order to provide optimum surgical
treatment.