Strangle hernia in the children! not always, amyand hernia with appendicitis

The description of an abdominal hernia can take into account two factors: either the location or the content of the hernia. If the hernia is described according to the location, we can call inguinal, femoral, Spigel, obturator, lumbar, sciatic, diaphragmatic or incisional hernias. Three types of hernia have been described according to their content: Littré’s hernia (contains a Meckel diverticulum), Richter’s hernia (contains an antimesenteric part of the small intestine) or Amyand’s hernia [1]. The latter contains an acute appendicitis and was named in memory of Claudius Amyand, author of the fi rst appendectomy performed in the history of medicine in 1735, at St George’s Hospital in London, for acute appendicitis within an inguinal hernia [2].


Introduction
The description of an abdominal hernia can take into account two factors: either the location or the content of the hernia. If the hernia is described according to the location, we can call inguinal, femoral, Spigel, obturator, lumbar, sciatic, diaphragmatic or incisional hernias. Three types of hernia have been described according to their content: Littré's hernia (contains a Meckel diverticulum), Richter's hernia (contains an antimesenteric part of the small intestine) or Amyand's hernia [1]. The latter contains an acute appendicitis and was named in memory of Claudius Amyand, author of the fi rst appendectomy performed in the history of medicine in 1735, at St George's Hospital in London, for acute appendicitis within an inguinal hernia [2].

Cas report
This is a 2-month-old patient with a history of reducible right inguino-scrotal hernia, admitted for management of right inguino-scrotal swelling of irreducible infl ammatory appearance ( Figure 1) for 6 hours prior to admission, associated with vomiting and transit disorder, with a fever of 38.7.On general examination, the infant was hemodynamically and respiratorily stable, and on objective local examination there was right inguino-scrotal swelling of irreducible infl ammatory appearance with redness and a testis that was not palpable on the right due to local edema ( Figure 1). No abnormalities were noted on the biologic (WBC: 10,3 ×10 9 /L, CRP:5mg/L) and radiologic work-up. The patient was taken to the operating room for management of a strangulated inguinal hernia.
Intraoperatively the body of the appendix were stuck to the hernia sac. The appendix was perforated with an infl amed distal part ( Figure 2). The base of the appendix and the cecum were normal and the testis was viable. An appendectomy and closure of the hernial sac was performed. The patient received 3 days of cefoxitin 80 mg/kg/day. The postoperative sequelae were uneventful. No complications were noted.

Discussion
The positional variations of the cecum and appendix allow

Abstract
The diagnosis of acute appendicitis is sometimes diffi cult to make. Among the atypical presentations is Amyand's hernia. This is the development of acute appendicitis within an abdominal hernia. Amyand's hernia is a rare but important disease to know. This pathology bears the name of the English surgeon, Claudius Amyand, operator of the fi rst appendectomy in the history of medicine in 1735, performed for an acute appendicitis inside an inguinal hernia. Here we present a case of Amyand's hernia in a 2-month-old male, who presented as a right-sided congenital hernia with pain in the right groin. He underwent herniotomy, which revealed that the hernia sac containing infl amed appendix. Thus, the discovery of appendicitis inside a hernia obturator [3,4], Spigel's [5,6], umbilical [7], diaphragmatic, intrathoracic [8][9][10], incisional [11] or in a laparoscopic trocar port [12] has been described. Right inguinal and femoral hernias are the most common site for the development of an Amyand's hernia, but this entity has also been described on the left side [13]. Among  incarcerated hernias containing viscera, the presence of the appendix is estimated to be 1% [14,15]. The development of acute appendicitis within a hernia sac (Amyand's hernia) is estimated to be 0.13% of all appendicitis [14].
The clinical presentation of an Amyand's hernia is that of a strangulated hernia, that is, the development of a nonreducible inguinal arch, but without digestive occlusion. An infl ammatory syndrome may develop depending on the course of acute appendicitis [16].
The diagnosis of Amyand's hernia is diffi cult to make and is often discovered intraoperatively if surgery is decided quickly.
Delay or failure to treat can be fatal. Indeed, Carrey described a mortality rate of three out of ten patients with Amyand's hernia in the 1960s [13]. Today, diagnostic capabilities have improved signifi cantly and computed axial tomography (CT) scans are available for preoperative diagnosis [17,18] (Figure 3).
Surgically, when a non-infl amed appendix is discovered during elective hernia repair, it is advisable to perform an inguinal appendectomy and hernia repair without the use of prosthetic material because of the risk of bacterial contamination [1,16,19]. In the case of Amyand's hernia with acute appendicitis, the surgeon will also perform an inguinal or abdominal appendectomy if the periapendicular infl ammation is extensive. The cure of the hernia will of course be done without prosthetic material.

Conclusion
Amyand's hernia is a rare but important disease to know.
Its clinical picture is similar to that of a strangulated hernia.
Amyand's hernia generally has a good prognosis, although serious complications have been described. So a surgeons must be prepared to avoid the eff ect of surprise and ensure adequate care without further complications.

Ethical considerations
The patient's parents confi rmed the patient's approval