Perforated Appendicitis in an Incisional Hernia P. G. Horgan, J. O'Donoghue, D. Courtney
Department of Surgery, University College Hospital, Galway. A generous incision was made in the skin overlying the now empty hernia and a corrugated drain left in situ for free drainage. The margins of the fascial defect were approximated with interrupted 1 nylon sutures from within, and the abdomen closed with continuous 1 nylon. A wick of ribbon gauze soaked in Betadine solution was left in the hernia cavity and in the subcutaneous tissues of the midline wound. The patient was nursed in the intensive care unit and was extubated 12 hours post surgery. The wound and hernia packs were soaked for 5 days with betadine solution and then removed. Antibiotics were continued for five days. Bacteriology reported growth of the expected mixture of anaerobic and aerobic intestinal pathogens which were sensitive to the antibiotic regimen in use. Recovery was uneventful and she was discharged home on the tenth postoperative day.
Introduction Incarcerated appendicitis has been described in femoral and inguinal hernias. However, the finding of acute appendicitis in an incisional hernia is rare. The authors describe a case report of a perforated appendicitis in this situation. Case Report A sixty-two year old obese lady presented to the casualty department of UCHG with a five day history of cramping central abdominal pain. This was associated with anorexia, nausea, vomiting, and constipation. Twenty years previously she had undergone a total abdominal hysterectomy via a lower abdominal transverse incision, and a left inguinal hernia repair. She had been aware of the presence of a large, asymptomatic, left sided, abdominal incisional hernia for many years. On presentation she was pyrexial at 38.2~ and in some distress with abdominal pain. On examination she had an obvious large incisional hernia with marked erythema of the surrounding skin. Palpation of the abdomen revealed diffuse peritonitism with exquisite tenderness over the incisional hernia. Bowel sounds were absent both in the hernia and the remainder of the abdomen. Haematological assessment showed a raised white cell count at 13,000 with a polymorphonuclear count of over 90%. Erect plain film radiology of the abdomen showed multiple gas-fluid levels. A pre-operative working diagnosis of a strangulated incisional hernia was made. The patient was commenced on intravenous antiobiotics (cephalosporin & metronidazole). A nasogastric tube and urethral catheter were passed. Intravenous rehydration was instituted to rescuscitate until a urinary flow of >0.5 ml/kg/ hour was achieved. At laparotomy through an upper midline incision, free intraperitoneal pus was noted. A specimen was aspirated for bacteriological assessment. Multiple loops of small bowel, appendix, caecum and much of the right colon was seen to be incarcerated into a left sided incisional defect. The mouth of the fascial defect was wide with sharp margins from which free pus was draining. The incarcerated viscera were reduced with some difficulty and a perforated gangrenous appendix noted. Following amputaion of the appendix without burial of the stump, loops of bowel were gently separated, washed with warm saline and inspected. There was no loss of viability of the tissues with normal colour mesenteric arterial pulsations and peristalsis. The hernia sac was excised with little difficulty and the defect copiously irrigated with saline as was the peritoneal cavity generally.
Discussion Acute appendicitis has protean presentations. It may mimic many other intra-abdominal illness and accurate diagnosis depends on meticulous history taking and on physical examination. The most important physical sign is the demonstration of point tenderness in the right iliac fossa. The condition remains one of the commonest acute surgical illness presenting for operation, and is usually the first surgical procedure undertaken by the junior surgeon in training. The experienced surgeon will be aware of the occasional difficulty in diagnosis which is especially prone to arise when the appendix is situated in an unexpected anatomical location. Giurguis et all in 1989, described the presentation of an acute appendicitis within a femoral hernia causing a necrotising fascitis of the groin and thigh. The diagnosis in this report was made at operation. In a similar publication, Rose and Cosgrove 2 in 1988, described a femoral canal appendicitis which they repaired using a preperitoneal repair. Khatib in 19873, described a femoral appendicitis in association with a strangulated loop of bowel, and went on to suggest that lack of awareness of the possibility of this occurrence would lead to delay in treatment. Thomas et al4 describe a series of seven patients with appendicitis in external herniae. Four were situated in the right femoral canal and three in the right inguinal canal. Once more in no case was the diagnosis even suspected preoperatively. Three patients developed a wound infection. Owens and Opalek ~ reported on the reduction en masse of a strangulated appendix in an incarcerated inguinal hernia. This report describes the finding of a perforated appendix within an incarcerated incisional hernia. It may be postulated that as the organ was located within the confines of the hernia, potential interference with its arterial supply or venous drainage may occur, precipitating the development of acute appendicitis. Histological analysis failed to demonstrate an obstructing aetiology such as a faecolith or catarrhal inflam-
Correspondence to: Mr. Paul Horgan, Surgical Professorial Unit, University College Hospital, Galway. 350
VoL 160 No. I1
Perforated Appendicitis in an Incisional Hernia 351
mation. We would emphasise the importance of meticulous peritoneal toilet with or without the addition of antibiotics or antiseptic solutions, and the principle of leaving the wound open allows adequate drainage and healing by secondary intention. References
1. Guirguis, E. M., Taylor, G. A., Chadwick, C. D. Femoral appendicitis: an unusual case. Can. J. Surg. 1989: 32, 5, 380-381.
2. Rose, R. H., Cosgrove, J. M. Perforated appendix in the incarcerated femoral hernia. A place for preoperitoneal repair. NY State J M 1988: 88, 11,600-602. 3. Khafib, C. M. Strangulated femoral hernia containing acute gangrenous appendicitis: case report and review of the literature. Can. J. Surg. 1987:
3o, 1,50. 4. Thomas, W. E., Vowles, K. D., Williamson, R. C. Appendicitis in external herniae. Ann. R. Coll. Surg. Engl. 1982: 64, 2, 121-122. 5. Owens, A. P., Opalak, M. E. Strangulated appendix in an incarcerated inguinal hernia reduced en masse. Conn. Med. 1982: 46, 2, 66-68.
Department of Surgery, University College Hospital, Galway. A generous incision was made in the skin overlying the now empty hernia and a corrugated drain left in situ for free drainage. The margins of the fascial defect were approximated with interrupted 1 nylon sutures from within, and the abdomen closed with continuous 1 nylon. A wick of ribbon gauze soaked in Betadine solution was left in the hernia cavity and in the subcutaneous tissues of the midline wound. The patient was nursed in the intensive care unit and was extubated 12 hours post surgery. The wound and hernia packs were soaked for 5 days with betadine solution and then removed. Antibiotics were continued for five days. Bacteriology reported growth of the expected mixture of anaerobic and aerobic intestinal pathogens which were sensitive to the antibiotic regimen in use. Recovery was uneventful and she was discharged home on the tenth postoperative day.
Introduction Incarcerated appendicitis has been described in femoral and inguinal hernias. However, the finding of acute appendicitis in an incisional hernia is rare. The authors describe a case report of a perforated appendicitis in this situation. Case Report A sixty-two year old obese lady presented to the casualty department of UCHG with a five day history of cramping central abdominal pain. This was associated with anorexia, nausea, vomiting, and constipation. Twenty years previously she had undergone a total abdominal hysterectomy via a lower abdominal transverse incision, and a left inguinal hernia repair. She had been aware of the presence of a large, asymptomatic, left sided, abdominal incisional hernia for many years. On presentation she was pyrexial at 38.2~ and in some distress with abdominal pain. On examination she had an obvious large incisional hernia with marked erythema of the surrounding skin. Palpation of the abdomen revealed diffuse peritonitism with exquisite tenderness over the incisional hernia. Bowel sounds were absent both in the hernia and the remainder of the abdomen. Haematological assessment showed a raised white cell count at 13,000 with a polymorphonuclear count of over 90%. Erect plain film radiology of the abdomen showed multiple gas-fluid levels. A pre-operative working diagnosis of a strangulated incisional hernia was made. The patient was commenced on intravenous antiobiotics (cephalosporin & metronidazole). A nasogastric tube and urethral catheter were passed. Intravenous rehydration was instituted to rescuscitate until a urinary flow of >0.5 ml/kg/ hour was achieved. At laparotomy through an upper midline incision, free intraperitoneal pus was noted. A specimen was aspirated for bacteriological assessment. Multiple loops of small bowel, appendix, caecum and much of the right colon was seen to be incarcerated into a left sided incisional defect. The mouth of the fascial defect was wide with sharp margins from which free pus was draining. The incarcerated viscera were reduced with some difficulty and a perforated gangrenous appendix noted. Following amputaion of the appendix without burial of the stump, loops of bowel were gently separated, washed with warm saline and inspected. There was no loss of viability of the tissues with normal colour mesenteric arterial pulsations and peristalsis. The hernia sac was excised with little difficulty and the defect copiously irrigated with saline as was the peritoneal cavity generally.
Discussion Acute appendicitis has protean presentations. It may mimic many other intra-abdominal illness and accurate diagnosis depends on meticulous history taking and on physical examination. The most important physical sign is the demonstration of point tenderness in the right iliac fossa. The condition remains one of the commonest acute surgical illness presenting for operation, and is usually the first surgical procedure undertaken by the junior surgeon in training. The experienced surgeon will be aware of the occasional difficulty in diagnosis which is especially prone to arise when the appendix is situated in an unexpected anatomical location. Giurguis et all in 1989, described the presentation of an acute appendicitis within a femoral hernia causing a necrotising fascitis of the groin and thigh. The diagnosis in this report was made at operation. In a similar publication, Rose and Cosgrove 2 in 1988, described a femoral canal appendicitis which they repaired using a preperitoneal repair. Khatib in 19873, described a femoral appendicitis in association with a strangulated loop of bowel, and went on to suggest that lack of awareness of the possibility of this occurrence would lead to delay in treatment. Thomas et al4 describe a series of seven patients with appendicitis in external herniae. Four were situated in the right femoral canal and three in the right inguinal canal. Once more in no case was the diagnosis even suspected preoperatively. Three patients developed a wound infection. Owens and Opalek ~ reported on the reduction en masse of a strangulated appendix in an incarcerated inguinal hernia. This report describes the finding of a perforated appendix within an incarcerated incisional hernia. It may be postulated that as the organ was located within the confines of the hernia, potential interference with its arterial supply or venous drainage may occur, precipitating the development of acute appendicitis. Histological analysis failed to demonstrate an obstructing aetiology such as a faecolith or catarrhal inflam-
Correspondence to: Mr. Paul Horgan, Surgical Professorial Unit, University College Hospital, Galway. 350
VoL 160 No. I1
Perforated Appendicitis in an Incisional Hernia 351
mation. We would emphasise the importance of meticulous peritoneal toilet with or without the addition of antibiotics or antiseptic solutions, and the principle of leaving the wound open allows adequate drainage and healing by secondary intention. References
1. Guirguis, E. M., Taylor, G. A., Chadwick, C. D. Femoral appendicitis: an unusual case. Can. J. Surg. 1989: 32, 5, 380-381.
2. Rose, R. H., Cosgrove, J. M. Perforated appendix in the incarcerated femoral hernia. A place for preoperitoneal repair. NY State J M 1988: 88, 11,600-602. 3. Khafib, C. M. Strangulated femoral hernia containing acute gangrenous appendicitis: case report and review of the literature. Can. J. Surg. 1987:
3o, 1,50. 4. Thomas, W. E., Vowles, K. D., Williamson, R. C. Appendicitis in external herniae. Ann. R. Coll. Surg. Engl. 1982: 64, 2, 121-122. 5. Owens, A. P., Opalak, M. E. Strangulated appendix in an incarcerated inguinal hernia reduced en masse. Conn. Med. 1982: 46, 2, 66-68.
