Amyand’s Hernia Complicated With Acute Appendicitis in a Severe Morbidity Obesity Patient

INTRODUCTION: An Amyand’s hernia is a heterogeneous clinical condition dened by the presence of the vermiform appendix within an inguinal hernia sac, which may or may not contain other abdominal contents or pathologic inammatory changes. Herein we present an exceptionally rare case of an Amyand’s hernia containing a suppurative appendix and omentum on a morbidity obesity patient , in order to improve our understanding of this disease, avoid misdiagnosis and share experience in the treatment. management we our


Introduction
Inguinal hernias are one of the most common clinical problems which need surgical repairs intervention, with more than 20 million inguinal herniorrhaphies performed every year worldwide [1,2]. When the hernia sac of inguinal hernias contains an appendix with or without appendicitis, it is named Amyand's hernia.
Amyand's hernia is a rare type of inguinal hernias, which named after the surgeon Claudius Amyand [3]. The incidence of Amyand's hernia is less than 1% of the total inguinal hernia cases. When the Amyand's hernia presents with complications such as in ammation, abscess formation or perforation, the incidence of this emergency case becomes as rare as about 0.1% [4].
Although there are studies reported cases with Amyand's hernia, the appropriate surgical treatment should be made based on the condition of appendix, the characteristics of the hernia, the comorbidities and other circumstances of the patient. In the present study, we report a case of an Amyand's hernia presented with acute suppurative appendicitis on a severe morbidity obesity patient. The pathophysiology, diagnosis, and management of Amyand's hernia are also discussed.

Presentation Of Case
A 35-year-old male obesity patient (Body mass index, BMI 41.22kg/m 2 ) presented to the Emergency  Department with 36 h of lower abdominal pain near the right groin and the McBurney point as well as nausea and fever. The pain was stuffy and constant, and got worse while getting up or movement within the right groin region. He reported a surgical history of a prior left inguinal hernia and a comorbidity of diabetes. The diabetes was treated with medication, but it was not well controlled. The patient did not know about his right inguinal hernia, because there was no pain or symptoms before.
During physical examination in the Emergency Department, the patient was hemodynamically stable. The BMI of the patient is 41.22kg/m 2 , with the ultrosonic abdomen and encircled neck. The abdominal exam showed mild tenderness to palpation over the right lower abdomen near the mcburney's point, but there was no rebound or guarding. Due to the thickness of subcutaneous fat, there was no mass or tenderness in the right inguinal region. No remarkable signs found in the rest of his physical exam.
The laboratory test showed a leukocy-tosis of 12.26 k/uL, neutrophile granulocyte of 10.55 k/uL, neutrophile granulocyte percentage of 86.1. The arterial blood gas analysis showed a lactate of 1.6mmol/L. The metabolic and biochemistry showed a Bun of 9.51 mmol/L, and the value of Cr was 119 umol/L. The value of glucose was 13.83mmol/L. The patient was initially diagnosed as acute appendicitis according to the laboratory tests and the clinical presentation. Then, A Computed tomography (CT) scan was performed in the Emergency Department and con rmed an inguinal hernia that contained part of the in amed appendix and the omentum. The nal diagnosis of Amyand's hernia was supported.
An attempt hernia reduction was made with a dose of 12 mg morphine, but it was not succeed. Because of the co-existence of acute appendicitis and inguinal hernia, the patient was scheduled for an emergent operation. Laparoscopic approach was applied to perform the appendectomy. The appendicitis was con rmed with exudative and suppurative uid around, and the hernia was found containing part of the in amed appendix and omentum. The adhesion and edema of the omentum and the mesoappendix were tied and severe (Fig. 1). Due to the morbidity obesity and the severe in ammation around, it took a relatively long time to dissect the in amed appendix and its mesenteriolum. Then, the malodorous and exudative uid was irrigated and extracted. After that, the hernia was reduced and the peritoneal cavity was lavaged. Considering the morbidity risks and surgically technical di culty brought with the severe morbidity obesity, the hernia defect was not repaired simultaneously. Besides, due to the coexisting myocardial ischemia indicated by the electrocardiogram, the operating time should be short. The resected appendix displayed suppurative in ammation with brinous adhesions, but was not perforated.
After the operation, electrocardiograph monitoring, oxygen Inhalation, and antibiotics et al were administrated. The pain was controlled by oral medication. There was no postoperative complication. When the patient tolerated the recovered diet well, he was discharged on postoperative day seven. The patient returned to clinic two weeks after the surgery and was found to be recovering well.

Discussion
The pathophysiology of Amyand's hernia complicated with appendicitis is still debated. It is supported that this type of Amyand's hernia is initiated by a fecalith or lymphoid hyperplasia which caused the appendix obstructed in the hernia sac. Then, the appendix within the hernia sac becomes entrapped and in amed because of the original obstruction [5]. However, these only accounts for parts of the cases complicated with appendicitis. Another explaination for the development of appendicitis in the hernia sac is that the sudden increased intraabdominal pressure and external muscular compression lead to the ischemia and in ammation of appendix. The incidence of Amyand's hernia complicated with appendicitis is rare [4]. As a result of the rareness and atypical presentation indistinguishable from the incarcerated hernia, reports on the experiences in diagnosis and management of Amyand's hernias are still lacking.
Usually, there is a lack of symptoms speci c to the Amyand's hernia, which increases the di culty in identifying this disease according to the clinical symptom. The present case showed stuffy lower abdominal pain and nausea, with mild tenderness to palpation near the mcburney's point. Both the symptoms and physical examination indicate a diagnosis of appendicitis. The lower abdominal pain got worse while getting up or movement within the right groin region. However, due to the thickness of subcutaneous fat, there was no positive physical sign of hernia. Thus, CT scan and/or ultrasound examination is of great value in identifying the Amyand's hernia with acute appendicitis. Moreover, the diagnosis of Amyand's hernia with appendicitis should be distinguished from Richter's hernia, inguinal lymphnoditis, strangulated omentocele, and acute epididymitis.
The management of Amyand's hernia is guided by the classi cation created by Losanoff and Basson based on intraoperative ndings [6,7]. When the appendix is not in amed, only hernia reduction with mesh repair is suggested and the resection of appendix is not proposed by most authors. However, other authors suggest a prophylactic removal of the appendix, because of it being prone to re-herniate and causing future appendicitis [4]. When the appendix is in amed and/or perforated, it is suggested that the removal of appendix and the repair of hernia without mesh should be performed. This classi cation scheme is useful as a general guidance, but the treatment should be tailored to individual patient because of the variability in Amyand's hernia and speci c condition of patient.
Apart from the BMI, the patient presented with co-morbidities including hypertension, diabetes, and renal insu ciency in the present study. The severe obesity and co-morbidities were reported to increase the risk of operative complications [8,9]. Moreover, the severe obesity is associated with increased technical di culty in operation and prolonged operative duration. Considering the above risks as well as the technical di culty, the surgical operation was ended after the appendectomy and peritoneal irrigation. During the operation, the precise distinguishing of appendix and omentum is vital for the following dissection of appendix. Because the mesenteriolum and omentum were severely in amed, every step of resection should be conducted carefully. During the follow-ups, the patient was normal with blood sugar levels controlled with oral medication. The patient was advised to receiving a proper mesh repair at later day.

Conclusion
The treatment of Amyand's hernia should be tailored to individual conditions and the intraoperative ndings. When this disease encounters the severe obesity, the surgical management could be challenged with technical di culty and increased risks of perioperative complications. As a rare case with varieties, the present case may contributes some information and experience in the management of Amyand's hernia on morbidity obesity patients. The present study is a case report, and ethical approval is not required. The present study does not involve data that can identify the patient. Written informed consent was obtained from the patient.

Consent for publication
Written informed consent was obtained from the patient for publication.

Availability of data and materials statement
All the data supporting the conclusions of this article are included in the present article. Additional data upon requirement are available from the corresponding author upon reasonable request.
YLG, WQL and DBL participated in the treatment of this patient. YLG and HJ designed and drafted the manuscript, with advice and assistance from WQL. DBL and FL revised the nal manuscript. All authors had read and approved the nal manuscript.