Annals of Medicine and Surgery 71 (2021) 102964 Contents lists available at ScienceDirect Annals of Medicine and Surgery journal homepage: www.elsevier.com/locate/amsu Case Series Amyand’s hernia- outcome of nylon darn repairs after complicated appendix surgeries in a district hospital: case series Mahamudu Ayamba Ali a,*, Israel Hagbevor b, Mathew Yamoah Kyei c, Salifu Nanga d a Department of Surgery, School of Medicine, University of Health and Allied Science. Ho, Volta Region, Ghana b Surgical Unit, Margaret Marquart Catholic Hospital, Kpando, Volta region, Ghana c Department of Surgery, University of Ghana Medical School, Accra, Ghana d Department of Basic Science, School of Basic and Biomedical Science, University of Health and Allied Science. Ho - Volta Region, Ghana A R T I C L E I N F O A B S T R A C T Keywords: Introduction: Complicated appendix is a least expected sac content of inguinal hernias that always require ap- Complicated amyand hernia pendix surgery and hernia repair. The current recommendations for posterior wall repairs however, continue to Complicated appendix attract conflicting views as to which modality gives the best outcome in infected surgical wounds. New posterior Nylon darn wall repair methods with properties to withstand surgical site infections, minimise hernia recurrence, affordable Surgical site infection Appendicectomy and easy skill to acquire with a potential to be widely adopted are continuosly sort. Emergency inguinal hernia Aim: To determine the surgical outcomes of complicated Amyand Hernias repaired using the open tissue base Nylon Darn posterior wall re-enforcement method. Method: A retrospective review of medical records of patients who had surgery for emergency inguinal hernia with intra-operative confirmation of complicated appendix in the hernia sac from January 2015 to December 2020 at the Margaret Marquart Catholic Hospital, Kpando were included. Data on age, sex, clinical presentation, surgical procedure, intra-operative findings, post operative complications were captured and presented as descriptive statistics. Results: Twelve out of 286(4.6%) repairs were complicated Amyand Hernias in patients aged 6weeks to 76-years {median age 54.5-years}. Most of them were adults, long-standing hernias. All diagnosis were made on-table. Surgical site infections was the most frequent complication in types III and IV AHs which resolved with anti- biotic treatment. Conclusion: The incidence of complicated AHs is higher and should be anticipated in surgeries for long-standing complicated inguinal hernias. Even though complications were significantly associated with longer hospital stay, no second procedure or mortality was recorded. 1. Introduction reported in about 1.0% of inguinal hernias with pathological appendix detected in 0.10–0.13% [1–4]. Most AHs described in current literature Complicated inguinal hernia is a common pathology for which sur- are on table diagnosis with few reports of pre-operative imaging and gery is frequently carried out base on only clinical diagnosis. The bowel postmortem detections [3–5]. AH is believed to be three-fold higher in and omentum are the usual expected sac contents. An unexpected children than adults and more prevalent in male as well as right-sided normal or pathological appendix, reproductive organs (ovaries and hernias [6–8]. Left-sided AHs are however frequent in individuals tubes) or bladder may be encounted. An Amyand Hernia (AH) is a term with situs inversus, intestinal malrotation, loose redundant caecum and used to describe the presence of an appendix in the sac of an inguinal large or long appendices [8]. hernia [1]. In 1735, Cladius Amyand, King George II surgeon reported Complicated AHs often present with an irreducible painful groin the presence of a perforated appendix in the sac of an 11-year old boy’s swelling which is difficult to differentiate from complicated inguinal hernia [1]. This was an incidental intra-operative finding even though hernia clinically [2,8]. Continuous bowel movement in patients with an enterocutaneous fistula had developed prior to presentation. AH is complicated AHs have often led to delayed presenation or diagnosis with * Corresponding author. E-mail addresses: aayamba@uhas.edu.gh (M.A. Ali), futagbiisrael@yahoo.com (I. Hagbevor), matkyei@yahoo.com (M.Y. Kyei), snanga@uhas.edu.gh (S. Nanga). https://doi.org/10.1016/j.amsu.2021.102964 Received 7 September 2021; Received in revised form 14 October 2021; Accepted 14 October 2021 Available online 16 October 2021 2049-0801/© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). M.A. Ali et al. A n n a l s o f M e d i c i n e a n d S u r g e ry 71 (2021) 102964 poorer outcome [8]. The decision to preserve a normal appendix during 2. A perforated appendix AH repair is currently personalised. The decisions are partly based on 3. A gangrenous appendix the surgeon’s competence to perform appendicectomy without compli- 4. Pussy and or organised appendix mass cations, future occurrence of appendiceal disease and the usefulness of a preserved appendix for future conduit surgeries. In a diseased appendix A total of 12 patients records sattisfied the above criteria and were (eg. inflammed, perforation, abscess), appendicectomy with adminis- included in our series. tration of antibiotics and abscess drainage is a standard treatment to mitigate the potential of developing surgical site infection [2,9,10]. 2.1.1. Preoperarive treatment/optimisation However, the debate on the best way to strengthen the posterior wall All adults and adolescents patients were preoperative given the continues with conventional open tissue repair method offered widely following: Intravenous fluid (0.9% normal saline or Ringers lactate), despite the higher recurrence rates compaired to open or laparoscopic Intravenous antibiotics at emergency room and on table (ciprofloxacin mesh repairs. The risk of mesh infection in peritonitis, foecal leakage or 400mg/12-hourly and metronidazole 500mg/8-hourly), analgesia bacteria spread and the need for its removal is auguebly the major (intramuscular pethedine or intravenous paracetamol) and intranasal influential factor most surgeons avoid the standard open or laparoscopic oxygen administered. The child received 0.45% dextrose saline and mesh repairs [2,9,10]. Surgical site infections occurs in 5.5–50% with cefuroxime. Nasogastric tube and urethral catheters were passed in all related mortality between 5.5% and 30% among repairs in patients with patients. They were no preoperative blood transfusions, intensive care AHs which is feared to be higher in the subset with complicated units admissions or the use of ionotropic agents. appendices [2,11,12]. Losanoff JE and Basson MD, 2007 [13] classifi- cation scale of identifying AHs and specific treatment recommendations 2.1.2. Investigations for various categories are currently evolving with large amount of There was no diagnostic imaging for any patient. Blood samples for literature on Bassini suture and open mesh repairs [14]. Reports on the supportive investigations:-full blood count for haemoglobin levels, outcomes of complicated AHs repaired using nylon darn method re- white blood cell count andplatelets level, Blood urea nitrogen and cre- mains scant even though in theory, nylon monofilament suture is atitine level, liver function and proteins level were optimal for surgery. capable of maintaining a longer tensile strength which is required under They were counselled and both verbal and written consent obtained infectious conditions. This hernia repair method is also widely used in either from patients directly or parents in those below 18 years. low resource facilities particularly in Africa [15]. Nylon darn which is an open tension-free woven-mesh re-enforcement of the posterior wall 2.1.3. Surgery using nylon suture to approximate the conjoint tendon to the inguinal Six patients had general anaesthesia, intubated and cuffed which ligament as decribed by Hagbevor et al., 2021 [15] is affordable and included five adults with symptoms of peritonitis and the neonate.The easy to perform. This study apart from exploring the usefulness of nylon rest had regional anaethesia(spinal). darn in an infected surgical wound, will expand our knowledge on the All the adults and adolescents patients had nylon darn repairs prevalence of complicated AHs in emergency inguinal hernia surgeries through the oblique groin incisions made medial to the imaginary line of complications which to the best of our knowledge have not been re- the inguinal ligament over internal ring. Nylon 2 suture was used for ported in any large series. herniorraphy after herniotomy. Six patients had appendicectomy We present 12 cases of AH in emergency setting, seen and managed through the same goin incisions The neonate also had appendicectomy in relation to their presentation, surgical findings, and complications. and division of the patent processus vaginalis through the same incision. Five patients suspected of peritonitis had midline abdominal in- 2. Patients and method cisions. Two with healthy bowels had only appendicectomies and 3 had bowel resection for associated gangrene or perforation with end to end 2.1. Study patients selection anastomosis. The resections were 2 large bowel and a small bowel with end to end anastomosis. All surgical procedures were performed by a This was a retrospective cross-sectional study in which we retrieved trained urological surgeon. and reviewed consecutive records of 286 emergency inguinal hernia repaired at the Margaret Marquart Catholic Hospital (MMCH) between 2.1.4. Post-operatively 2015 and 2020. MMCH is a district level hospital at Kpando in the Volta Post-operatively, all patients recieved intravenous fluid and anti- region of Ghana with the 4 main clinical diciplines. Its medical/surgical biotic ranging from 24-hours for class II to 72-hours for Class III, IV emergncy and surgical units has 12 and 30 beds respectively where all (Table 1) and adequate analgesia before resumption of oral feeds and the patients except the baby were attended. commencement of oral antibiotics for 5–7days. The child recieved A 2-step criteria was followed to identify records included in this cefuroxime, 0.45% dextrose saline, 100 ml/kg in 24-h and suppository study. All records of admitted emergency inguinal hernia operated were acetamenophen 100mg/8-hourly. Two patients (5 & 12 from Table 1) confirmed from both the admission and theatre registers. Complicated were adminished ionotropics (adrenaline in infusion) to maintain blood AHs were then identified from operation notes and histopathogical pressure. confirmation. Surgical wounds were exposed between post operative day 2–3. Emergency cases where defined as inguinal hernias admitted wounds were cleaned with normal saline, dressed and covered with through the emergency unit with any of the following and had surgery povidine soaked gauze till stitches were removed. within 6-hours: Documentation of the following were sort for as complications post- operatively: 1. Pains at a swollen inguinal hernia 2. Incarcerated inguinal hernia 1. Discharging, oedematous wound to be infected wound 3. Intestinal obstruction resulting from irreducible inguinal hernia 2. Swelling of the scrotum to denote scrotal collection 4. Peritonitis resulting from inguinal hernia 3. Acute retention of urine 4. Wound bleeding Complicated Amyand Hernia included any of the following in the 5. Recurrence of swelling hernia sac: 6. Pains at incsion site after discharge 7. Fever related to the wound or surgery 1. An inflammed appendex 2 M.A. Ali et al. A n n a l s o f M e d i c i n e a n d S u r g e ry 71 (2021) 102964 Table 1 Demographic characteristics, presentation, treatment, complications and duration of hospital stay in complicated Amyand’s hernia repair in MMCH, Kpando. SN Age Sex duration of Duration of Laterality of Hernia sac content surgical intervention Losanoff & Duration of Complications hernia sympt hernia Basson class hosp. stay 1 46 y F 1 year 4 days RIH Viable terminal ileum & Appendictomy Nylon III 32 days SSI perforated Appendix in darn labia majus 2 53 y M 1 year 2 days RIH Viable caecum & Appendictomy nylon III 38 days SH, SSI and right perforated appendix darn groin pain 3 26 y M 5 mon 2 days RISH Viable large bowel Appendectomy & II 5 days SH Inflamed appendix Nylon darn 4 6 M 1 day 1 day RISH Viable small bowel & Appendectomy & II 4 days Nil wks Inflamed appendix division of PPV 5 63 y M 20 years 1 mon RIH Gangrenous large bowel Lap. Resection & IV 30 day SSI,SH And inflamed appendix anastomosis, Nylon Darn 6 56 y M 3 mon 3 days RISH Gangrenous caecum & Lap.Resection & IV 9 days ileus Small bowel, inflamed anastomosis, Nylon Appendix darn 7 65 y M 3 years 3 days RISH Viable large and small Appendectomy & II 4 days Nil Bowel, inflamed Nylon darn appendix 8 45 y M 1 year 1 day RISH Viable caecum and Appendectomy & II 4 das Nil Inflamed appendix Nylon darn 9 69 y M 1 year 21 days LISH Viable large bowel, Appendectomy & II 5 days Nil Urinary bladder and Nylon darn Inflamed appendix 10 17 y M 1 year 4 days RISH Gangrenous small bowel Lap. Resection & IV 4 day Nil Inflamed appendix anastomosis, Nylon darn 11 60 y M 1 year 5 days RISH Viable caecum and Appendectomy & II 3 days Nil Inflamed appendix Nylon darn 12 76 y F 5 years 7 days LIH inflamed appendix in Left Appendectomy & II 8 days ileus hernia sac Nylon darn M − Male, F – Female, y – year, mon – Month, wks – weeks, RIH: Right inguinal hernia, LIH-Left Inguinal Hernia, RISH – right inguinoscrotal hernia, LISH – left inguinoscrotal hernia, SSI – surgical site infection, SH – scrotal haematoma, Obst – obstructed, sympt – symptom. POD6-post operative day 6, PPV-patent processus vaginalis, Lap. Resection & anastomosis-Laparotomy, gangrenous bowel resection with end-to-end anatomosis 2.2. Data extraction All patients presented with irreducible groin swelling varying from a day to 30days after onset of symptoms with no significance difference Patients age, gender, clinical presentations, preoperative diagnosis, (p-valve > 0.05) between various pathologic categories (Table 2). Other surgical findings, treatment techniques and postoperative outcome were clinical symptoms and signs presented also included pain and tender of analysed. Patient information was presented in a table form. Descriptive groin swelling, vomiting, constipation, abdominal distension and statistics was employed to describe the features of the data. Descriptive generalised malaise. Seven patient had fever with temperatures analysis was carried out to summarize the characteristics of the subjects >37.5 ◦C, 5 patient dehydrated, 2 patients were hypertensive and 1 case base on tables, frequency distribution tables, percentages, bar charts and had bilateral inguinal hernias with incisional ventral hernia. stacked bar charts. The non-parametric Kruskal test was carried out to Contents of the hernia sac: In 75% of the patients, the appendix ascertain whether significant difference existed between the categories herniated with bowel with 50% (6/12) being large bowel and 25% (3/ of pathology identified and average durations of symptoms before hos- 12) small bowel. Two (2/12) patients had a combination of both large pital admission and hospital stay. The non-parametric Fisher exact test and small bowel and one person had the urinary bladder and large bowel of association was also employed to determine relationships between with the appendix. We found 7 inflamed appendices of which 2 were pathology identified and surgical intervention. adhered to the caecum. Three appendices were with gangrenous bowel This study is registered as required by the Helsinki declaration 2013 and 2 perforated (Table 2). involving data from human participants with unique number Resear- All patients had open procedure to remove the appendix and nylon chregistry7082- www.researchregistry.com [16]. Ethical clearance was darn repair of the posterior wall through groin incisions. Five patients in obtained from the University for Health and Allied Sciences Ethical addition, had extended midline laparatomy incisions of which 2 had Review Committee Ref: UHAS-REC A.417119-20. In addition, permis- large bowel resections and one had small bowel resections with ileocolic sion of the hospital administration was obtained for the study. The reporting of this study was in line with the Proceed criteria by Agha et al., 2020 [17]. Table 2 Intra-operative pathology and post-operative outcome in hospital. 3. Results AH Pathology n Symptom SSI SC Days of class identified duration range hospital stay & Of the 286 emergency hernias repaired over the six year period, pre-hospital & (average)/days twelve (4.2%) were complicated Amyand’s hernias. Patients age range (average)/days was between 6weeks and 76 years(median age 54.5-years). The ratios of II Inflammed 7 1-21 (5.7) nil 1 3 - 8(4.7) male to female, right to left-sided AHs and adults to under 18-years were III Perforated 2 2 - 4 (3) 2 1 30,38(34.0) each 5:1. Hernia duration prior to complication varied from congenital IV Gangrene + 3 3 - 30 (12.3) 1 1 4 - 30(14.3) P-value: >0.05 0.015 <0.05 (noticed at birth) to 20 years with majorty (75%) of the hernias longer than a year. AH-Amyand Hernia, SSI-Surgical Site Infection, SC-Scrotal Collection, n-number of patients in the category base on Loffner and Banson 2007 classification. 3 M.A. Ali et al. A n n a l s o f M e d i c i n e a n d S u r g e ry 71 (2021) 102964 end-to-end anastomosis. In the 7 persons with inflammed appendix, appendicectomy and nylon darn repair or division of patent processus vaginalis(neonate) done through the groin incision (Fig. 1). There was no mortality recorded. The post operative hospital stay ranged from 3 days to 38 days with significant difference (P-value < 0.5) between the pathogical categories (Table 2). Patients developed SSI were 25% (3/12) and mainly with perforated and gangrenous pathology (Fig. 2) and 25% (3/12) with none recorded in the class II or imflammed appendices with a significant difference (Table 2). Other complications were scrotal collection 30%(3/10) of the men, paralytic illeus and groin pains (Fig. 2). 4. Discussion Inguinal hernia with complicated appendicitis remains a rarely re- ported encounter in surgical practice with an incidence of about 0.07–0.1% [2,4–6,12]. In this series however, the recorded 4.2% in complicated inguinal hernias is among the highest [3–5]. This high incidence may be partly related to the high incidence of complicated Fig. 2. Complications by categories of complicated appendix following surgery. hernias which are often long standing (>1 year) in health deprived communities and high mobility from loose redundant caecum which is which denotes hernia. Common sac contents in hernia are bowel and associated with diet in Africa or guts malformation manifesting in adults omentum. However, the urinary bladder, female reproductive organs, [3]. Adults constituted 75%, a finding that supports our believe that Meckel’s diverticulum (Littre’s hernia) and the appendix are occasion- emergency obstruction, long standing hernias and diet is associated, ally seen [15,19–21]. The protrusion is often prominent to patients and contrary to published literature where the pathology is more prevalent clinicians during physical examination which makes the diagnosis of in children [6,7,18]. In addition, majority of the patients 91.7% (11/12) complicated hernia most likely. In this study, the appendices were out of the age bracket 12–20 years that are predominantly seen co-herniated commonly with bowel in 75% of the patients and urinary with acute appendicitis [8]. The pathogenesis of acute appendicitis is bladder in one. Diagnosis were made intra-operative which has been the generally related to luminal obstruction from faecolith and lymphoid trend in reported cases of complicated AH. Even though the type of hyperplasia [11,18]. However, the compression of the bowel wall, blood appendiceal complication or hernia often pre-determine the incision and vessels and the appendix during intestinal obstruction or strangulation is treatment modality, surgeon skills in these unexpected cases influences theorised to traumatise the appendix, causes thrombosis of the appen- the choice of open repair verse laparoscopic intervention, and mesh deceal vessels or stasis of luminal content [19]. This, we believe pre- verses tissue repair of posterior wall. In this series, appendicectomy disposed majority of our cases to irreversible ischemia and infection through groin incision with nylon darn was performed for acute since there were no identifiable risk factors to explain the pathogenesis inflammation while lower midline laparatomy incision was performed except the presence of obstruction in these hernia cases. The ratio of 5:1 for suspected perforated or gangrenous bowel based on our skill and right-side to left AHs is consistent with other studies [8]. we however hospital set-up. Complications were significantly different in the various noticed a late reporting of symptoms with the left complicated AHs in intra-operative findings (p-value 0.015) which could influence the this series (Table 1). choice of mesh for posterior wall repairs (Table 2). The SSI,scrotal col- Clinical presentation of appendix pathology is dependand on the lections which were recorded resolved with antibiotics without clinical type of complication(inflammation, perforation, abscess or mass) and problems. Although laparoscopic surgical intervention has been re- the progression. These inflammatory process are classically different ported in some studies with advantages, the practice is not widely used from abdominal viscous protrusion through the anterior abdominal wall in Africa and other deprived communities [22]. In the classification scale designed by Losanoff JE and Basson MD 2007, to identify and treat AHs, Seven (58.3%) were acute appendicitis(type 2) and had appendi- cectomy of which the six adults had nylon darn repair through groin incision. The type III & IV categories were treated with laparotomy and appendicectomy or bowel resection respectively and nylon darn through groin incision. The baby was treated with appendicectomy and division of patent processus vaginalis (Fig. 2). These treatment combinations are consistent with the tissue repair proposed with added advantages from the nylon suture used. Surgical site infection was 25%(3/12) compared to recent reports by Cai et al., 2018 [23], however patients responded satisfactorily with antibiotics. There was no recurrence immediate or 1-year average follow-up which could be considered a better benchmark for good repair. None of the complicated cases required a second pro- cedure or removal of repair material and no mortality. Ileus, scrotal collection resolved spontaneously while a single patient was managed with chronic pains on follow-up. Fig. 1. Surgical procedures for categories of complicated Amyand Hernias. 5. Conclusion Category II-appendicectomy and Nylon darn repair/division of patent processus vaginalis for child. This preliminary study showed that the incidence of complicated III- Laparotomy + appendicectomy + nylon darn. AHs 4.2% in surgeries for complicated IH is higher than previous IV- laparotomy + appendicectomy + bowel resection and anastomosis + thought with late presentation noticed among left-sided AH patients. nylon darn. 4 M.A. Ali et al. A n n a l s o f M e d i c i n e a n d S u r g e ry 71 (2021) 102964 Complicated AHs should therefore be anticipated in any adult with an mon Month emergency from long-standing inguinal hernias. Although nylon darn wks weeks repairs after visceral surgery for types III and IV AHs was significant RIH Right inguinal hernia associated with SSI, standard antibiotic treatment resulted in satisfac- RISH right inguinoscrotal hernia tory outcome with no recurrence, mortality or need to reintervene. This LISH left inguinoscrotal hernia modality we consider a good alternative treatment in complicated AH SH scrotal haematoma especially in resource deprived facilities. Obst obstructed sympt symptom 5.1. Limitations POD6 post operative day 6 PPV patent processus vaginalis This was a preliminary study and retrospective with often limited and uncontrolled variables that maybe analysed and a rather smaller Appendix A. Supplementary data study sample size. Supplementary data to this article can be found online at https://doi. 5.2. Recommendations org/10.1016/j.amsu.2021.102964. 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