Historically, discovering the appendix in the inguinal sac was an incidental intraoperative finding, but this has become less common with increased use of CT. In our case, CT prepared the surgical team to (1) expect a sharp in the field and (2) expect a difficult laparoscopic reduction of the appendix from the hernia sac—the tip of the hemming needle passed through the wall of the appendix into the hernia sac, anchoring it within the sac. Periappendiceal inflammation also produced a tethering effect on the hernia sac. Perhaps the relatively larger size of the tip of the appendix relative to the thinner body of the appendix in the inguinal canal predisposed our patient to a difficult reduction requiring open exploration and repair. CT accurately depicted all these features and can do so for all types of Losanoff and Basson’s Amyand hernia classification system.
Appendectomy—whether laparoscopic, through the hernia sac, or via laparotomy—and concurrent or delayed inguinal hernia repair is the treatment for Amyand hernia with appendicitis [2, 5]. Open inguinal exploration may be needed to completely reduce the appendix if laparoscopic attempts fail. Inguinal hernia repair at the time of this operation was contraindicated due to the acute inflammation and foreign body and risk for subsequent wound infection.
Children have a higher incidence of foreign bodies in the appendix due to the higher incidence of accidental ingestion. The majority of foreign bodies that are ingested will pass without problem through the GI tract. Less than 1% of these foreign bodies become entrapped in the appendix due to gravity and its position to the cecum while both upright and supine [8, 9]. When a foreign body is found within the appendix, sharp objects, like our patient’s needle, are more likely to cause perforation than blunt objects . The sharp objects tend to cause rupture within days, while the blunt objects can present with recurrent abdominal pain, acute appendicitis, or asymptomatically . When managing a patient with suspected ingestion of a foreign body, serial physical exams and radiographs should be taken. If not progressing and possibly entrapped, CT should be used to localize the object in the appendix .
Acute appendicitis has a relatively high incidence in pediatric patients, but diagnosis can be delayed because an estimated one-third of children present abnormally . Perforation is more frequent in children than adults, so accurate imaging needs to be available for surgical management. CT is a valuable imaging modality to diagnose this condition as it allows for better visualization of a retrocecal appendix and is able to delineate extent of inflammation and abscess formation. It also has less interference from air in the bowel, adiposity, and operator error than US . Our patient’s appendix was likely chronically herniated in the relatively fixed shape of the inguinal canal, giving it a small diameter in the canal and a more bulbous tip in the superior hemiscrotum. This anatomic spatial constraint may have made our patient unable to expel a foreign body from the appendix once it reached the inguinal canal, effectively predisposing him to perforation and appendicitis.