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Perforated appendix in hernial sac mimicking torsion of undescended testis in a neonate
Journal of Pediatric Surgery (2008) 43, E9–E10
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Perforated appendix in hernial sac mimicking torsion of undescended testis in a neonate Renu Kumar, J.K. Mahajan⁎, K.L.N. Rao Department of Pediatric Surgery, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India Received 12 August 2007; revised 18 November 2007; accepted 22 November 2007
Key words: Amyand's hernia; Torsion testis; Appendicitis
Abstract In pediatric surgical practice, finding of the vermiform appendix in an inguinal hernia sac is not that uncommon; however, a perforation is rare. There are only a few case reports of a perforated appendix with periappendicular abscess in the inguinal hernial sac in a neonate. We report an unusual case of inguinal hernia containing a perforated appendix that was clinically mimicking testicular torsion of the undescended testis. © 2008 Published by Elsevier Inc.
The finding of an appendix in an inguinal hernia is more common than finding a Meckel's diverticulum in it (Littre's hernia). It was Claudius Amyand who performed the first ever appendectomy in an 11-year-old boy with inguinal hernia and fecal fistula in the groin. But Claudius Amyand did not enjoy the eponymous immortality as Littre [1]. Extensive search of pediatric surgery literature revealed only a few case reports of Amyand's hernia in neonates; however, its occurrence was quite rare. Iuchtman [2] reported neonatal pyoscrotum with perforated appendicitis in a 6-day-old male child. Similarly, Singh et al [3] reported appendicitis in a hernia sac in 13-day-old male child. Celik et al [4] described a sliding appendiceal inguinal hernia with preoperative sonographic diagnosis in a 3-month-old boy. Gupta et al [5] reported a rare presentation of left-sided Amyand's hernia in a 9-month-old infant. In adult surgical literature, perforated appendix in an inguinal hernia has been estimated to occur in 0.1% to 0.13% of all cases of appendicitis [6,7]. We report an ⁎ Corresponding author. Tel.: +91 172 2749495, +91 172-2755325; fax: +91 172 2744401. E-mail address: [email protected] (J.K. Mahajan). 0022-3468/$ – see front matter © 2008 Published by Elsevier Inc. doi:10.1016/j.jpedsurg.2007.11.031
unusual case of inguinal hernia containing perforated appendix with periappendicular abscess mimicking torsion of an associated undescended testis in a neonate. A 26-day-old male term baby, weighing 3.4 kg, was detected to have a right-sided undescended testis (UDT). However, parents did not notice any swelling in the inguinal region after birth. He presented to outpatient department with history of excessive crying and increasing swelling and redness in the right groin for 2 days. There was no history of vomiting, fever, chills, or urinary symptoms. The baby was irritable but accepting feeds normally. On examination, the baby was well hydrated and general systemic examination did not reveal any abnormality. Biochemical and hematologic laboratory parameters were normal. Local examination revealed a 3 × 4-cm swelling in the right inguinal region with induration and erythema. The right hemiscrotum was empty (Fig. 1). The left testis was normal. Based on these findings, a clinical diagnosis of torsion of the right UDT was made, and nuclear scintigraphy was performed to check the viability of the testis. There was no photopenic area at the site of inguinal swelling; however, a definite conclusion could not be drawn because of the undescended position of the testis.
E10
R. Kumar et al.
On exploration of right inguinal region, the sac containing the UDT was found that on opening, discharged purulent material. The hernial sac also contained appendix that was perforated at the tip and adhered to the swollen and inflamed testis and epididymus (Fig. 2). The spermatic cord was edematous, but there was no twisting or rotation on itself. An appendectomy was performed through the inguinal incision alone, and the hernia sac was ligated. A thorough lavage of the wound was done, and the testis was pexed in the subdartos pouch. The scrotal wound was drained for a few days. The baby recovered well and was fed on second postoperative day and was sent home on sixth postoperative day. It is a unique association of its kind in neonatal surgical anomalies. Although, testicular torsion becomes an obvious differential diagnosis in a neonate with an inflamed inguinal swelling and an empty scrotum; incarcerated hernia with or without strangulation, Litter's hernia, and suppurative inguinal lymphadenitis should also be considered. The reported incidence of risk of incarcerated hernia younger than the age of 3 months is 28% to 31%, but its association with UDT is not known [8]. The occurrence of Amyand's hernia is not only restricted to adults, children, and infants but can also occur in neonates and may mimic obstructed or strangulated hernia whether the appendix is inflamed or not. The presence of an UDT on the same side adds a new dimension to the diagnostic dilemmas. Surgical exploration is the best means of excluding testicular torsion. Despite the fact that testicular scan was not suggestive of torsion, we still decided to explore the inguinal region to confirm the diagnosis and perform orchiectomy or orchiopexy as the case may be, keeping in mind the fallacies in the interpretation of radionuclide testicular scan. Moreover, all the clinical conditions in differential diagnosis would merit surgical exploration; hence, the investigations
Fig. 1
Right inguinal swelling with empty scrotum.
Fig. 2 Hernial sac containing perforated appendix and UDT (marked by a forceps).
become redundant in such a scenario except when required for prognostication. The diagnosis of appendicitis within the inguinal hernia sac is made only intraoperatively [9]. For “hernial appendicitis,” the usual treatment is appendectomy through the herniotomy incision alone with primary hernia repair [10]. The associated UDT may also be brought down to the scrotum at the same time if the vascularity is not compromised or else pexed to the pubis symphysis for subsequent scrotal orchiopexy. Amyand's hernia can occur without any abdominal signs as in our case. In Amyand's hernia with appendicular perforation, inflammation is limited by the hernia sac; therefore, the signs as seen in an abdominal appendicitis are concealed.
References [1] Hutchison R. Amyand's hernia. J R Soc Med 1993;86:104-5. [2] Iuchtman M, Kirshon M, Feldman M. Neonatal pyoscrotum and perforated appendicitis. J Perinatol 1999;19:536-7. [3] Singh I, Aggrawal A, Lewis E. Neonatal appendicitis. N Y State J Med 1986;86:109-10. [4] Celik A, Ergun O, Ozbek SS, et al. Sliding appendiceal inguinal hernia: preoperative sonographic diagnosis. J Clin Ultrasound 2003; 31:156-8. [5] Gupta S, Sharma R, Kaushik R. Left sided Amyand's hernia. Singapore Med J 2005;46:424-5. [6] Pellegrino JM, Feldman SD. Case report: acute appendicitis in an inguinal hernia. N J Med 1992;89:225-6. [7] Ryan WJ. Hernia of the vermiform appendix. Ann Surg 1937;106: 135-9. [8] Rescorla FJ, Grosfeld JL. Inguinal hernia repair in the perinatal period and early infancy: clinical considerations. J Pediatr Surg 1984;19: 832-7. [9] Lyass S, Kim A, Bauer J. Perforated appendicitis with an inguinal hernia: case report and review of literature. Am J Gastroenterol 1997; 92:700-2. [10] Davis MG, O'Byne P, Stephens RB. Perforated appendicitis presenting as an irreducible inguinal hernia. Br J Clin Pract 1990;44:494-519.
www.elsevier.com/locate/jpedsurg
Perforated appendix in hernial sac mimicking torsion of undescended testis in a neonate Renu Kumar, J.K. Mahajan⁎, K.L.N. Rao Department of Pediatric Surgery, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India Received 12 August 2007; revised 18 November 2007; accepted 22 November 2007
Key words: Amyand's hernia; Torsion testis; Appendicitis
Abstract In pediatric surgical practice, finding of the vermiform appendix in an inguinal hernia sac is not that uncommon; however, a perforation is rare. There are only a few case reports of a perforated appendix with periappendicular abscess in the inguinal hernial sac in a neonate. We report an unusual case of inguinal hernia containing a perforated appendix that was clinically mimicking testicular torsion of the undescended testis. © 2008 Published by Elsevier Inc.
The finding of an appendix in an inguinal hernia is more common than finding a Meckel's diverticulum in it (Littre's hernia). It was Claudius Amyand who performed the first ever appendectomy in an 11-year-old boy with inguinal hernia and fecal fistula in the groin. But Claudius Amyand did not enjoy the eponymous immortality as Littre [1]. Extensive search of pediatric surgery literature revealed only a few case reports of Amyand's hernia in neonates; however, its occurrence was quite rare. Iuchtman [2] reported neonatal pyoscrotum with perforated appendicitis in a 6-day-old male child. Similarly, Singh et al [3] reported appendicitis in a hernia sac in 13-day-old male child. Celik et al [4] described a sliding appendiceal inguinal hernia with preoperative sonographic diagnosis in a 3-month-old boy. Gupta et al [5] reported a rare presentation of left-sided Amyand's hernia in a 9-month-old infant. In adult surgical literature, perforated appendix in an inguinal hernia has been estimated to occur in 0.1% to 0.13% of all cases of appendicitis [6,7]. We report an ⁎ Corresponding author. Tel.: +91 172 2749495, +91 172-2755325; fax: +91 172 2744401. E-mail address: [email protected] (J.K. Mahajan). 0022-3468/$ – see front matter © 2008 Published by Elsevier Inc. doi:10.1016/j.jpedsurg.2007.11.031
unusual case of inguinal hernia containing perforated appendix with periappendicular abscess mimicking torsion of an associated undescended testis in a neonate. A 26-day-old male term baby, weighing 3.4 kg, was detected to have a right-sided undescended testis (UDT). However, parents did not notice any swelling in the inguinal region after birth. He presented to outpatient department with history of excessive crying and increasing swelling and redness in the right groin for 2 days. There was no history of vomiting, fever, chills, or urinary symptoms. The baby was irritable but accepting feeds normally. On examination, the baby was well hydrated and general systemic examination did not reveal any abnormality. Biochemical and hematologic laboratory parameters were normal. Local examination revealed a 3 × 4-cm swelling in the right inguinal region with induration and erythema. The right hemiscrotum was empty (Fig. 1). The left testis was normal. Based on these findings, a clinical diagnosis of torsion of the right UDT was made, and nuclear scintigraphy was performed to check the viability of the testis. There was no photopenic area at the site of inguinal swelling; however, a definite conclusion could not be drawn because of the undescended position of the testis.
E10
R. Kumar et al.
On exploration of right inguinal region, the sac containing the UDT was found that on opening, discharged purulent material. The hernial sac also contained appendix that was perforated at the tip and adhered to the swollen and inflamed testis and epididymus (Fig. 2). The spermatic cord was edematous, but there was no twisting or rotation on itself. An appendectomy was performed through the inguinal incision alone, and the hernia sac was ligated. A thorough lavage of the wound was done, and the testis was pexed in the subdartos pouch. The scrotal wound was drained for a few days. The baby recovered well and was fed on second postoperative day and was sent home on sixth postoperative day. It is a unique association of its kind in neonatal surgical anomalies. Although, testicular torsion becomes an obvious differential diagnosis in a neonate with an inflamed inguinal swelling and an empty scrotum; incarcerated hernia with or without strangulation, Litter's hernia, and suppurative inguinal lymphadenitis should also be considered. The reported incidence of risk of incarcerated hernia younger than the age of 3 months is 28% to 31%, but its association with UDT is not known [8]. The occurrence of Amyand's hernia is not only restricted to adults, children, and infants but can also occur in neonates and may mimic obstructed or strangulated hernia whether the appendix is inflamed or not. The presence of an UDT on the same side adds a new dimension to the diagnostic dilemmas. Surgical exploration is the best means of excluding testicular torsion. Despite the fact that testicular scan was not suggestive of torsion, we still decided to explore the inguinal region to confirm the diagnosis and perform orchiectomy or orchiopexy as the case may be, keeping in mind the fallacies in the interpretation of radionuclide testicular scan. Moreover, all the clinical conditions in differential diagnosis would merit surgical exploration; hence, the investigations
Fig. 1
Right inguinal swelling with empty scrotum.
Fig. 2 Hernial sac containing perforated appendix and UDT (marked by a forceps).
become redundant in such a scenario except when required for prognostication. The diagnosis of appendicitis within the inguinal hernia sac is made only intraoperatively [9]. For “hernial appendicitis,” the usual treatment is appendectomy through the herniotomy incision alone with primary hernia repair [10]. The associated UDT may also be brought down to the scrotum at the same time if the vascularity is not compromised or else pexed to the pubis symphysis for subsequent scrotal orchiopexy. Amyand's hernia can occur without any abdominal signs as in our case. In Amyand's hernia with appendicular perforation, inflammation is limited by the hernia sac; therefore, the signs as seen in an abdominal appendicitis are concealed.
References [1] Hutchison R. Amyand's hernia. J R Soc Med 1993;86:104-5. [2] Iuchtman M, Kirshon M, Feldman M. Neonatal pyoscrotum and perforated appendicitis. J Perinatol 1999;19:536-7. [3] Singh I, Aggrawal A, Lewis E. Neonatal appendicitis. N Y State J Med 1986;86:109-10. [4] Celik A, Ergun O, Ozbek SS, et al. Sliding appendiceal inguinal hernia: preoperative sonographic diagnosis. J Clin Ultrasound 2003; 31:156-8. [5] Gupta S, Sharma R, Kaushik R. Left sided Amyand's hernia. Singapore Med J 2005;46:424-5. [6] Pellegrino JM, Feldman SD. Case report: acute appendicitis in an inguinal hernia. N J Med 1992;89:225-6. [7] Ryan WJ. Hernia of the vermiform appendix. Ann Surg 1937;106: 135-9. [8] Rescorla FJ, Grosfeld JL. Inguinal hernia repair in the perinatal period and early infancy: clinical considerations. J Pediatr Surg 1984;19: 832-7. [9] Lyass S, Kim A, Bauer J. Perforated appendicitis with an inguinal hernia: case report and review of literature. Am J Gastroenterol 1997; 92:700-2. [10] Davis MG, O'Byne P, Stephens RB. Perforated appendicitis presenting as an irreducible inguinal hernia. Br J Clin Pract 1990;44:494-519.