This case describes the presentation and management of an 18-month-old male child with a strangulated left AH. AH is more commonly observed in males than females. This predominance is linked to the higher occurrence of a patent processus vaginalis in boys. It can affect all age groups, showing a bimodal age distribution in infants and the elderly since the size of the internal inguinal ring varies with age, being relatively large at birth, narrowing during midlife, and enlarging again with advancing age (11, 13). In their retrospective analysis, Almetaher et al. (2020) presented 12 pediatric patients aged between 15 days and five years with right AH and operated in their tertiary referral hospital. Ten out of the 12 children were boys. (4)
In the 20-year systematic review conducted by Manatakis et al. (2021), the left AH has been reported in about 42 (9.5%) of the 442 cases (children and adults). Children accounted for 42.5% of cases (18 cases). After that review, we identified another two cases in children, one in a 2-month-old male infant and the other in a 15-month-old male child. (11, 14, 15)
The child in our study presented to the emergency room with tenderness and a sudden increase in hernia size, along with greenish vomiting, indicating potential bowel obstruction. Physical examination revealed a tense and tender hernia, prompting further evaluation with laboratory tests and an abdominal ultrasound. Diagnosing AH preoperatively can pose challenges, often presenting as incarcerated inguinal or inguinoscrotal swellings. Surgeons should be vigilant about this rare condition, especially when encountering an irreducible hernia without typical signs of intestinal obstruction. Clinical examinations of AH can reveal incarceration without the symptoms and signs of intestinal obstruction as mentioned by Almetaher et al. (2020). Symptoms like fever, vomiting, and abdominal distention may vary depending on the condition of the appendix, whether inflamed or perforated. The possible conditions that may be mistaken for AH are broad and may comprise irreducible, incarcerated, or strangulated hernia, acute appendicitis, urological emergencies, and cutaneous complications. Imaging techniques such as inguinoscrotal ultrasonography and CT scan are crucial for accurate prediction and diagnosis. (4, 16)
The appendix within the hernia sac is usually discovered incidentally during planned hernia surgeries. However, not all cases of the appendix moving into the inguinal canal result in acute appendicitis, and the lower likelihood of the appendix becoming trapped and inflamed in an inguinal hernia may be explained by the inguinal ring being wider and more flexible than the femoral ring. (16–18)
According to the classification of AH presented by Losanoff and Basson (Table 1), and as our case did not have any manifestation of peritonitis or an abscess, we opted for laparoscopic management. Of course, if the diagnosis is unclear, laparoscopy is helpful (19, 20).
Table 1
Types of Amyand's hernia and their management
| Type of hernia | 1 | 2 | 3 | 4 |
| Salient features | Normal appendix | Acute appendicitis localized in the sac | Acute appendicitis, peritonitis | Acute appendicitis, other abdominal pathology |
| Surgical Management | Reduction or appendectomy (depending on age), mesh hernioplasty | Appendectomy through hernia, endogenous repair | Appendectomy through laparotomy, endogenous repair | Appendectomy, diagnostic workup and other procedures as appropriate |
In our study, meticulous port insertion allowed for a comprehensive view of the abdominal cavity. Intestinal loops caught in the left internal ring were identified and reduced using careful maneuvers to avoid injury to the bowel. In our case, we discovered a mobile caecum as the etiology. That is in agreement with Joshi et al. (2022) who reported that there was no situs inversus or intestinal malrotation observed in their patient and concluded that a mobile caecum was the likely cause for the left-sided nature of the hernia in their case. (15)
For type 1 hernias, considering the patient's age and lifelong risk of appendicitis is crucial before deciding on appendix removal. Routine appendectomy is not universally recommended, as even elective procedures raise the risk of complications. The choice between mesh - rarely used in infants or children- or endogenous tissue repair for type 2 hernias depends on specific surgical circumstances. (19, 20)
The approach to dealing with a normal-looking appendix in pediatric patients with AH remains a topic of debate. While it is generally agreed upon that appendectomy should be performed in cases of AH with appendicitis, there are controversies regarding AH cases where the appendix appears normal (4, 21–23). Many authors argue that a normally looking appendix incidentally discovered during surgery, without any signs of inflammation, should not be removed, and prophylactic appendectomy is unnecessary (4, 24, 25). They suggest that unnecessary appendectomy may increase operative risks, potentially lead to the dissemination of infection, and weaken tissues at the incision site, possibly resulting in recurrence. Additionally, the appendix may have future utility in other surgical procedures, such as urinary diversion. This perspective is supported by a case series study, where keeping the normally looking appendix and repairing AH were performed in 11 patients without postoperative complications or recurrences. (4)
On the other hand, some authors advocate for appendectomy in all AH patients. They argue that the high likelihood of appendix herniating in young patients, leading to recurrence, may predispose them to later appendicitis (4, 21–23). Luciana et al. (2019) reported right-side AH in a 2-year-old male who came to the emergency department with a history of irreducible lump along with right scrotal tenderness 6 hours before admission and progressively increased. There is no specific sign of obstruction, dehydration, or infection. In contrast to our case, this patient did an open repair of hernia as diagnostic and therapeutic; identification of the appendix was a non-inflamed appendix inside the right scrotum, with no sign of incarceration, strangulation, or perforation. No complications were reported until two months postoperative. They choose to perform appendectomy for this case with a satisfying outcome. (3)
Furthermore. in cases of AH with acute appendicitis, recurrent hernial cases, and in cases of left AH to prevent further diagnostic delays in cases of acute appendicitis (4, 7, 26, 27), and those cases where adhesion of the appendix with hernial sac is encountered, wherein the vascularity of the appendix is compromised, we believe that the removal of the appendix is justified. Otherwise, if the appendix can be readily reduced without compromising its blood supply, a preventive appendectomy is not necessary (1). In our case of left AH, we did not remove the appendix because it was non-inflamed, and its blood supply was not compromised.
A laparotomy might be required in a few instances with clinical signs and symptoms of a suspected severe strangulated inguinal hernia. However, the inguinal approach is generally sufficient to treat most cases with AH (7, 26). De Almeida et al. (27) reported a 7-month-old infant with strangulated AH, necessitating a laparotomy. During the procedure, ischemic necrosis of the caecum, terminal ileum, and appendix was discovered, requiring resection and ileocolic anastomosis. In a similar vein, Singh et al. reported a 1.5-year-old male child who suffered from strangulation and had primary repair for a caecal perforation. (28)
Although the open herniotomy is a well-established technique for repairing inguinal hernias in pediatric patients, laparoscopic repair is becoming increasingly popular due to its advantages, including reduced postoperative pain, shorter hospital stays, and earlier return to daily activities. We opted for laparoscopic management in our case as we believe that laparoscopy presents a multifaceted advantage over open techniques. As a diagnostic tool, it provides unparalleled precision, particularly in discerning the complex pathology of left-sided AH. It aids in identifying anatomical anomalies such as situs inversus totalis, malrotation, and mobile caecum, ensuring treatment planning. Moreover, it minimizes the risk of overlooking an inflamed appendix. By allowing for meticulous assessment and reduction of herniated contents without undue traction, it facilitates the safe evaluation of the strangulated appendix and surrounding viscera. Additionally, laparoscopic appendicectomy can be seamlessly integrated into the repair process, reducing contamination risk, and enabling efficient management of left-sided AH. Various techniques have been described for laparoscopic inguinal hernia repair in pediatric patients, including the closure of the internal ring, the division of the hernia sac, and the use of sutures, staples, or mesh to secure the repair. (29, 30)
In our current case, we chose to disconnect the hernia sac and then tighten the internal ring using continuous 3/0 prolene sutures between the transversus abdominis muscular arch and the iliopubic tract, respecting the contents of the internal ring. Continuous sutures have been demonstrated to lower the recurrence rate in laparoscopic hernia repair compared to interrupted sutures. (31)
In our case, the entrapped intestine was reduced through gentle manipulations from the inside, combined with gentle external pressure on the swelling by the surgeon's and assistant's fingers. This method was found to be safe and effective for reducing incarcerated inguinal hernias in children. One potential complication of laparoscopic inguinal hernia repair is injury to the testicular vessels or vas deferens, which can result in testicular atrophy or infertility (32). In this current case, careful attention was paid to protect the vas and gonadal vessels during the disconnection of the sac from the peritoneal cavity.
In our case, the absence of malrotation of the colon but the presence of a mobile cecum and oedematous internal ring were noted during the procedure. Repairing of the ileopubic tract with continuous sutures and narrowing of the internal ring was performed to prevent hernia recurrence. Careful dissection protected vital structures such as the vas and vessels. Following the successful surgical intervention, the child had a straightforward postoperative course and was discharged after 6 hours of surgery. Subsequent follow-up appointments showed no complications, indicating a favorable outcome of the procedure. Several studies have reported comparable outcomes between open and laparoscopic repair regarding recurrence rates, complication rates, and postoperative pain. However, laparoscopic repair may offer advantages such as shorter hospital stays, earlier return to normal activities, and improved cosmesis. (33)
In conclusion, this case highlights the importance of prompt diagnosis and appropriate surgical management in pediatric patients with groin hernias to prevent complications and ensure optimal outcomes. Also, laparoscopic reduction and repair of an incarcerated left-sided inguinal hernia is a safe and effective procedure in pediatric patients. It offers several advantages over open techniques and is a suitable alternative for the repair of pediatric inguinal hernias particularly left-side AH.