Case Report

Sliding Appendiceal Inguinal Hernia:Preoperative Sonographic Diagnosis

Ahmet Celik, MD,1 Orkan Ergun, MD,1 S. Sureyya Ozbek, MD,2 Zafer Dokumcu, MD,1 Erol Balık, MD1

1 Department of Pediatric Surgery, Ege University Faculty of Medicine, Bornova 35100 I.zmir, Turkey

2 Department of Radiology, Ege University Faculty of Medicine, Bornova 35100 I.zmir, Turkey

Received 9 May 2002; accepted 21 August 2002

ABSTRACT: We report the case of a 3-month-old boywith a right-sided sliding appendiceal inguinal herniathat was diagnosed preoperatively with sonography.Surgery was performed, and intraoperative and histo-pathologic evaluations also revealed changes in theappendix that could have led to complications if leftuntreated. The infant’s recovery was uneventful, andhe was discharged on the second day after surgery.This condition is usually diagnosed intraoperatively,and to the best of our knowledge, this is only the sec-ond report in the English-language medical literaturein which such a case was correctly diagnosed preop-eratively with sonography. In our case, the early sono-graphic diagnosis led to early intervention and theavoidance of potential complications. © 2003 WileyPeriodicals, Inc. J Clin Ultrasound 31:156–158, 2003;Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jcu.10146

Keywords: hernia, inguinal; hernia, sliding; hernia,Amyand’s; appendix; ultrasonography

The presence of the vermiform appendix withinan inguinal hernial sac is not uncommon.1–4

Most cases are diagnosed intraoperatively ratherthan preoperatively. Appendicitis within an in-guinal hernial sac, however, is rare. Very fewcases are recognized preoperatively,5,6 and mostare complicated by and associated with symptomsof acute scrotal disorders.1,3–5,7,8 Although rou-tine sonographic evaluation of an inguinal herniais not necessarily recommended, sonographic ex-amination of any mass in the groin is justified. Wereport here the case of a sliding appendiceal in-guinal hernia diagnosed preoperatively by sonog-raphy and confirmed by surgery.

CASE REPORT

A 3-month-old boy with a 10-day history of inter-mittent swelling in the right groin and scrotumwas referred to our pediatric surgery department.Physical examination revealed a right-sided in-guinal hernia whose proximal portion was reduc-ible but whose distal portion contained a thick,cord-like palpable structure (Figure 1) extendingtoward the scrotum. An appendiceal sliding her-nia was suspected, and the patient was referredto our radiology department for sonographicevaluation.

Sonographic examination was performed witha Sonoline Elegra ultrasound scanner (Siemens,Issaquah, WA) and a 7.5-MHz multifrequency lin-ear-array transducer. Sonography confirmed thepresence of a right-sided inguinal hernia contain-ing the appendix (Figure 2). The appendix wassonographically visualized as a tubular, noncom-pressible structure 5 mm in diameter. Transversescanning of the structure demonstrated con-centric layers of its wall, confirming its intestinalorigin. The structure could be temporarily andpartially reduced by compression with the trans-ducer. The sonographic findings were interpretedas representing a herniated and inflamed appen-dix in the right hernial sac.

Surgery was performed through an incision ina skin crease in the right groin. The hernial sacwas dissected in an orderly fashion, and the ap-pendix was found to be adherent to the base of thesac. Macroscopically, the appendix appeared erec-tile and hyperemic, suggesting chronic compres-sion and irritation and probably impeded venousreturn (Figure 3). Appendectomy with inversionof the stump, followed by high ligation for repairof the hernia, was curative. The patient’s postop-

Correspondence to: A. Celik

© 2003 Wiley Periodicals, Inc.

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erative course was uneventful, and he was dis-charged on postoperative day 2. Histopathologicevaluation of the specimen revealed periappen-dicular edema and vascular dilatations sugges-tive of chronic irritation and impeded venousdrainage.

DISCUSSION

The incidence of inguinal hernia peaks during in-fancy and childhood.9 A common type of inguinalhernia is the sliding hernia, in which the wall ofthe abdominal viscus forms a portion of the her-nial sac and the parietal peritoneum forms theremainder. Many types of sliding hernias havebeen described,9,10 including the not uncommonsliding appendiceal inguinal hernia.1–4 Slidingappendiceal hernias account for 65% of all ingui-nal hernias containing an appendiceal structurein the sac.11

Obviously, an accurate preoperative diagnosisfacilitates surgical planning, and to that endsonography is very useful. Sonography is a rapid,reliable, convenient, and noninvasive techniquefor primary screening of intra-abdominal, pelvic,and abdominal wall abnormalities.12 Sonographicexamination of the inguinal region is also benefi-cial in detecting many other pathologic conditionsof the groin.13 In children, sonography offers highsensitivity (86%) and specificity (98%) for prob-lems related to the appendix.12 Chen et al

reported 98% accuracy in diagnosing childhoodinguinal hernias sonographically.13

Appendicitis within an inguinal hernia is arare event and has been the subject of small se-ries and case reports in the surgical literature.1–5,7,8

This condition was first described in the mid1700s by de Garengeot and Amyand.3,7,11,14 To

FIGURE 1. Preoperative photograph shows the palpable structure ex-tending toward the right hemiscrotum.

FIGURE 2. Sonograms demonstrate the appendix in the hernial sac.(A) Sagittal sonogram of the inguinal canal shows the herniated ap-pendix. (B) Transverse sonogram of the right scrotum shows the lo-cation of the herniated appendix in relation to the right testis. ap,appendix; s, sac; t, testis.

FIGURE 3. Intraoperative photograph shows the appendix in the her-nial sac.

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the best of our knowledge, only 2 reports in theEnglish-language medical literature since thenhave addressed correct preoperative diagnosis.5,6

Most often, particularly when it is complicated,1–4,7

the condition is clinically confused with an incar-cerated inguinal hernia.1,3–5,7,14,15

Preoperative sonographic detection of a slidingappendiceal hernia in a child was first describedby Akfırat et al in 1999.10 To the best of ourknowledge, ours is only the second such report.The presence of the appendix in the hernial sac isalmost always discovered either incidentally dur-ing surgery or after a complication has occurred.In our case, sonographic, intraoperative, and his-topathologic evaluations all revealed changes inthe appendix suggestive of preappendicitis thatcould have led to complications if left untreated.Therefore, early diagnosis and treatment contrib-uted to a fast and safe perioperative course withno morbidity.

We found sonography very useful in preopera-tively identifying and confirming a clinically sus-pected sliding hernia. We recommend routine pre-operative sonographic examination of any masssuspected of being a childhood sliding inguinalhernia and early surgery if the presence of theappendix within the sac is confirmed because ofthe possibility that complications may arise thatwould compromise the adjacent testis.

REFERENCES

1. Lyass S, Kim A, Bauer J. Perforated appendicitiswithin an inguinal hernia: case report and reviewof the literature. Am J Gastroenterol 1997;92:700.

2. Carey LC. Acute appendicitis occurring in hernias:a report of 10 cases. Surgery 1967;61:236.

3. Orr KB. Perforated appendix in an inguinal her-nial sac: Amyand’s hernia. Med J Aust 1993;159:762.

4. Korkmaz A. Perforated appendicitis in an incarcer-ated scrotal hernia. Jpn J Surg 1989;19:213.

5. Luchs JS, Halpern D, Katz DS. Amyand’s hernia:prospective CT diagnosis. J Comput Assist Tomogr2000;24:884.

6. Weber RV, Hunt ZC, Kral JG. Amyand’s hernia:etiologic and therapeutic implications of two com-plications. Surg Rounds 1999;22:552.

7. Logan MT, Nottingham JM. Amyand’s hernia: acase report of an incarcerated and perforated ap-pendix within an inguinal hernia and review of theliterature. Am Surg 2001;67:628.

8. Yasumoto R, Kawano M, Kawanishi H, et al. Leftacute scrotum associated with appendicitis. IntJ Urol 1998;5:108.

9. Grosfeld JL. Groin hernia in infants and children.In: Nyhus LM, Gondon RE, editors. Hernia. 3rd ed.Philadelphia: Lippincott; 1989. p 81.

10. Akfırat M, Kazez A, Serhatlıoglu S. Preoperativesonographic diagnosis of appendiceal inguinal her-nia. J Clin Ultrasound 1999;27:156.

11. Rose E, Santulli TV. Sliding appendiceal inguinalhernia. Surg Gynecol Obstet 1978;146:626.

12. Wong ML, Casey SO, Leonidas JC, et al. Sono-graphic diagnosis of acute appendicitis in children.J Pediatr Surg 1994;29:1356.

13. Chen K-C, Chu C-C, Chou T-Y, et al. Ultrasonog-raphy for inguinal hernias in boys. J Pediatr Surg1998;33:1784.

14. Hutchinson R. Amyand’s hernia. J R Soc Med 1993;86:104.

15. Oguzkurt P, Kayaselcuk F, Oz S, et al. Slidingappendiceal inguinal hernia with a congenital fi-brovascular band connecting the appendix vermi-formis to the right testis. Hernia 2001;5:156.

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