Fishbone-Induced Appendicular Perforation: A Rare Case Report of Amyand's Hernia

Abstract

Amyand's hernia is a rare type of hernia where the appendix is found to be the content of the inguinal hernial sac. It is most often diagnosed intraoperatively wherein the appendix may be found healthy, incarcerated, inflamed, or perforated. Claudius Amyand performed a successful appendectomy on a patient with an appendix noted in the inguinal canal and this condition was hence named after him. The incidence of Amyand's hernia is rare in inguinal hernia patients. There are no defined guidelines for the management of Amyand's hernia but adequate resuscitation followed by immediate appendectomy is widely followed. Here is a case report of a 60-year-old male presenting to the Emergency Department with an irreducible right-side inguinal hernia with features of small bowel obstruction. On exploration, Amyand's hernia was identified with appendicular tip perforation due to an impacted fishbone with pyoperitoneum. Appendectomy was done through midline laparotomy with impacted fishbone removal from the hernial sac with tissue repair of the hernia. There are as such no reported cases of fishbone-induced appendicular perforation in an Amyand's hernia in the available literature. After the exploration, we found the management of the case challenging regarding the closure of the hernia.

Keywords: amyand’s hernia; appendicular perforation; exploratory laporotomy; impacted fishbone in appendix; small-bowel obstruction; strangulated inguinal hernia.

Figure 1. Multiple air fluid levels suggestive of acute intestinal obstruction.

Figure 2. Pool of pus noted in hernial sac with impacted fishbone (white arrow).

Figure 3. Perforated appendix (white arrow) found within hernial sac.

Figure 4. Midline laparotomy done and appendix delivered through midline incision.