Amyand’s hernia is defined by the presence of the appendix in the inguinal hernia sac. It is a rare type of inguinal hernia with an unknown prevalence in the general population, which can be discovered during scheduled hernia repair or emergency hernia surgery [1]. Based on the evolution in the surgical treatment of inguinal hernia, its current treatment according to Losanoff-Basson classification poses two fundamental problems:

First, the presence of the appendix in the hernia sac may appear normal or pathological [1, 2]. Appendicular pathology has the particularity of having several degrees of infectious risk depending on the stage of the pathology. Thus, it may be a type 2 (Clean, Contaminated) surgery according to Altemeir’s classification of infectious risks in the case of a normal or catarrhal appendix, or be classified as type 4 (Dirty or Infected) in the case of perforation with the presence of pus in the hernia sac [1, 3]. This concept of infection in Amyand’s hernia has been taken into account in the Losanoff-Basson classification (Table 1), which facilitates understanding of the risk of infection and other possible complications in cases of Amyand’s hernia [1, 4]. However there is no consensus for appendectomy even for type 1 Losanoff-Basson Amyand’s hernia [5].

Secondly, modern hernia treatment is based on the absence of tissue tension during hernia repair. Over time, tension-free techniques have shown a drastic reduction in recurrence rates and improved patients' quality of life [6]. Most tension-free techniques use a mesh that can be placed using several methods, which aim to reinforce the posterior wall of the inguinal canal. The current gold standard for these techniques is the procedure described by Irving Lichtenstein in 1984 [7]. The main risk associated with the use of prostheses is infection, which may require excision of the prosthesis in extreme cases. Other techniques, such as the Desarda procedure, allow for tension-free repair without the need for a prosthesis [8]. In sub-Saharan Africa, the Bassini procedure, which is a tension repair technique criticised for its high recurrence rate, is still the most widely used. It has the advantage of a low risk of infection, is simple to perform and easy to learn [9]. We hereby question the place of pure tissue tension-free procedures in the management of Amyand’s hernia.

In this article, we present two patients treated for strangulated inguinal hernias containing the appendix and caecum and review the literature for evidence that may guide the choice of surgical treatment. The study was reported according to the CARE guidelines [10].

Amyand’s hernia is a type of hernia characterised by the presence of the appendix in the hernia sac. It was first described by Claudius Amyand in 1736, at a time when most hernia treatments were based on tissue repair. The two cases observed in our study were young adults aged 37 and 44 years old. This age group was equally reported in Matanakis' systematic review, although most cases observed are in children and the older adults [1, 11].

The two cases we report were diagnosed at surgery for a strangulated hernia. Most Amyand hernias are diagnosed in emergencies [1, 12]. This may lead to an underestimation of the prevalence of this type of hernia, as opening the hernia sac is only systematic in complicated hernias. In contrast, the appendix may also be present in uncomplicated hernias [1]. The mechanism of occurrence of this hernia is not exactly known. However, It has been reported that, the patency of the processus vaginalis predisposed children to Amyand’s hernia more than adults [13]. We did not identify any causes in our two patients. Furthermore, this hernia can also occur on the left side (9.5%), resulting from an anomaly such as situs inversus, intestinal malrotation or a mobile caecum [1].

The diagnosis in our two patients was made during surgical exploration. Matanakis also report this in his systematic review, where the majority of cases (281/442) were operated on as emergencies [1]. Amyand’s hernia does not present any specific clinical signs. During emergencies, the clinical picture seems to oscillate between that of a complicated hernia and acute appendicitis. Furthermore, the presence of a tubular structure in the hernia sac attached to the caecum with hyperaemia is pathognomonic of an Amyand hernia, and the presence of the caecum near an hernia orifice is suggestive [1]. These data can be obtained by ultrasound and CT scan [14]. Routinely, we only perform imaging in cases of serious doubt about a strangulated hernia.

The Losanoff-Basson classification is a guide to the appropriate surgical procedure, as it is based on the severity of appendicitis and possible associated abdominal pathology [4, 15]. Furthermore, its application may raise concerns with evolving concepts in the treatment of inguinal hernias, as inguinal hernias have been subject to extensive research. Based on some evidence in the literature, the following factors should be taken into account to guide surgeons in their choice of treatment:

According to Matanakis’ systematic review, appendicular pathology such as a neuroendocrine tumour, appendicular pseudomyxoma, or other tumours can be diagnosed on the appendectomy specimen during the treatment of an inguinal hernia [1, 11]. This factor argues in favour of routine appendectomy or peroperative histological examination, as macroscopic appearance alone is not sufficient to rule out appendicular pathology [11]. In both of our cases, the appendix appeared inflamed macroscopically, which was confirmed by histological examination.

New hernia repair techniques, such as Desarda’s technique, have proven effective in the treatment of inguinal hernias, both during emergencies and elective surgery, regardless of the infectious context [16]. In addition, in high-income countries, biological prostheses can be used because they are more resistant to infection. They can also be placed through the laparoscopic approach [12, 17]. In our two patients, a non-absorbable prosthesis was used, precautions such as protecting the surgical site before appendectomy were taken, and povidone-iodine was instilled on the prosthesis before closure. This is a standard practice in our centre when repairing hernias with mesh. Further studies are needed to examine the benefits of these procedures.

Finally, according to the review by Matanakis, appendectomy does not appear to increase morbidity and mortality in Amyand’s hernias, even for those operated on urgently [1, 11]. In cases operated during emergencies with insertion of prosthesis, infection of the surgical site was not associated with excision of the prosthesis [1]. One of our patients presented with oedema of cord after surgery but was successfully treated with enzymatic anti-inflammatory drugs made of on trypsin, pancreatic ribonuclease and chymotrypsinogen (Ribatran^R).

In conclusion most Amyand hernias are diagnosed during surgery for a hernia complication. There are no specific signs, hence the importance of systematically opening the hernia sac when treating a complicated hernia. During surgery, the surgeon must choose an appropriate repair technique based on the risk of infection and perform a systematic appendectomy with examination of the surgical specimen. The role of hernioplasty according to the Desarda procedure could be evaluated for this indication. The Losanoff-Basson classification must be constantly updated in line with developments in treatment procedures and available resources.