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claudius amyand first performed a successful appendectomy on an 11-year - old boy with a perforated appendix within an inguinal hernia sac in 1735 . in a recent report of 1950 patients with groin ( inguinal and femoral ) hernias ,
an appendix was found in 0.51% of cases , and acute appendicitis was found in 0.10% of all groin hernia sacs . a normal appendix within an inguinal hernia
the finding of appendicitis in the inguinal hernia is 0.08% in a series of 1341 inguinal hernia operations .
the appendix has even been found in left - sided inguinal hernias as well as in laparoscopic port - site hernias .
it has been shown that endoscopic total extraperitoneal treatment of amyand 's hernia can be accomplished . in this case report
, we describe a young adult who presented with an appendix mass 10 months after and as a direct result of a laparoscopic extraperitoneal bilateral inguinal hernia repair .
in august 2004 , a 22-year - old man had a laparoscopic extraperitoneal bilateral inguinal hernia repair . before this operation
, he had been complaining of a lump in the groin diagnosed as a left - sided , inguinoscrotal hernia . during the operation ,
he had a 30-hour history of periumbilical pain that had settled in his right iliac fossa .
this pain was associated with one episode of vomiting . on clinical examination , the patient was comfortable with mild pyrexia .
blood investigations showed a raised white blood cell count and a mildly elevated c - reactive protein .
three days after admission , a vague lump could be felt in the right iliac fossa , and an abdominal ultrasound scan was carried out .
this showed thick - walled matted bowel loops ; the proximal small bowel was dilated , suggestive of bowel obstruction . at this time
, the surgical team made a diagnosis of appendix mass , which was to be treated conservatively .
the patient 's inflammatory markers continued to remain elevated despite antibiotics , and a further ultrasound scan showed that fluid collection was present behind the bladder .
two weeks after discharge , he was well and his inflammatory markers had improved , but he continued to have a mass in his right iliac fossa and mild diarrhea .
it was decided that inflammatory bowel disease or malignancy must be excluded , and a computed tomographic ( ct ) scan and barium meal were arranged .
the ct scan showed inflammation around the appendix and small bowel , and a collection of fluid persisted behind the bladder .
two weeks later , a barium meal and follow through showed free flow of barium from the small bowel to the colon .
the patient was readmitted to the hospital on an emergency basis before this could be performed electively . on admission , he had right iliac fossa pain , a firm lump , and small bowel dilatation ( figure 1 ) .
the ct scan showed an inflammatory mass in the right iliac fossa ( figure 2 ) .
random biopsies were taken that showed no evidence of crohn 's disease . at this point
, a decision was made to perform a diagnostic laparotomy because the patient 's symptoms and condition were not improving . at laparotomy , an appendix mass was found .
the omentum and the appendix were fixed to the mesh from the previous repair , within the residual hernia sac .
the relationship between incarceration and inflammation of the appendix is not clear in amyand 's hernia .
the inflammatory swelling may lead to incarceration and subsequent impaired blood supply and bacterial over - growth .
as soon as the appendix enters the hernia sac , it becomes vulnerable to trauma and is ultimately retained there by adhesions .
its blood supply may subsequently be cut off or significantly reduced , resulting in inflammation and bacterial overgrowth .
preoperative ct scans have revealed the previously un - suspected diagnosis of amyand 's hernia in some reports .
the second ct scan visualized the inflammatory mass , and the involvement of the right hernia sac could not be seen .
this was complicated further by the fact that the omentum was also in the hernia sac .
laparoscopic extraperitoneal repair of inguinal hernia does not visualize the contents of the hernia sac , ie , appendix or omentum , so the contents can not be visually reduced .
if the contents can not be reduced completely , it would be advisable to change to a technique that can . in an open or laparoscopic transabdominal approach to inguinal hernia repair
it is not appropriate , after the appendix is easily reduced by these techniques , to perform an appendectomy , as the possibility of bacteremia must be kept to a minimum .
however , if significant trauma occurs to the appendix while it is being reduced , an appendectomy is indicated because the trauma induced to the appendix while being reduced would increase the risk of appendicitis developing postoperatively .
laparotomy for peritonitis or problems of releasing the appendix incarcerated into the deep inguinal ring has been performed and reported .
however , in our case , this was not an option because this was not technically possible as there was an appendiceal mass , and we needed to confirm a diagnosis and rule out crohn 's disease or malignancy .
appendicitis within an amyand 's hernia is rare , and when it occurs it is usually misdiagnosed as strangulated inguinal hernia . in this present case ,
amyand 's hernia and appendicitis presented as a right iliac fossa mass that did not respond to conservative treatment .
this was because the appendix and omentum were still in the hernia sac and chronically inflamed .
although laparoscopic extraperitoneal inguinal hernia is still acceptable in appropriate cases , this possible presentation and complication must always be remembered in this type of inguinal hernia repair and a limitation compared with the open or laparoscopic transabdominal approach to this type of hernia repair .
amyand 's hernia ( appendix in the sac of an inguinal hernia ) although rare is a fairly well - recognized clinical entity . 
 it is associated with an increased risk of developing appendicitis . 
 amyand 's hernia can be repaired by open or laparoscopic methods . 
 we present the case of a laparoscopic extraperitoneal repair with a potential hazard when repairing this type of hernia in this manner , and we review the literature on this condition .