An 88-year-old male presented with a right groin bulge and underwent preoperative imaging which indicated the presence of his appendix within his hernia. He was taken to the operating room electively where an appendectomy was performed due to significant chronic inflammatory changes. A lightweight mesh plug was used to repair the hernia to prevent recurrence. He did well post operatively without any complications.
An 88-year-old male presented in the outpatient surgical setting with a chief complaint of a right groin bulge that had been present for 6 weeks. He had sharp pain initially when he first developed the abnormality but had been asymptomatic ever since. He did not recall any inciting factors. He was concerned that a previously repaired right inguinal hernia had recurred from its original tissue repair in 1977. Details of the original right inguinal hernia repair were unknown to the patient, other than no implantation of mesh occurred. On physical examination, a 3 cm × 3 cm firm, nontender mass was palpable in the right groin just lateral to the pubic tubercle. A computed tomography scan of the abdomen and pelvis was performed to elucidate the cause of the mass in his groin (Figs. 1, 2, and 3). The imaging was relevant for a right inguinal hernia with the appendix present within the sac. Preoperative laboratory testing revealed a white blood cell count of 4.7 × 109/L. The patient elected to proceed with surgical intervention for hernia repair.
The patient presented to the hospital setting for his elective right inguinal hernia repair. A classic oblique incision was made in the right groin using the anterior superior iliac spine and pubic tubercle as landmarks. The external oblique aponeurosis was opened and the hernia isolated and examined. The hernia was noted to be comprised of an extremely hard and dense amount of omentum that had a chronic, scarred appearance. The base of the appendix could be seen exiting the internal inguinal ring, but the densely adhered omentum prevented reduction of the appendix back into the peritoneal cavity. Initially, there was no indication to perform an appendectomy at the time of the procedure if the appendix could be successfully reduced into the abdominal cavity. However, the chronic appearing adhesions in the area prevented this step. In order to reduce the appendix at that point, a relaxing incision was then made in the typical transverse fashion in the right lower quadrant through the rectus sheath, and the peritoneum entered. The appendix was clearly visualized exiting the abdominal cavity into the inguinal defect. The appendix and its adhered omentum were then carefully reduced back into the abdominal cavity using intraperitoneal countertension without any rupture or spillage. Due to its densely adherent chronic inflammatory tissue, an incidental appendectomy was performed as there was significant tension on the cecum after placing the appendix back in its anatomical location. There was concern for the development of appendicitis post operatively due to the manipulation performed during the procedure. The appendix was then stapled at its base using a standard gastrointestinal anastomosis stapler and passed off the field. The indirect hernia defect was very small and closed with a medium size lightweight mesh plug. The patient was discharged from the post-anesthesia care unit the same day as surgery and had no complications from his recovery course. No additional antibiotics were given other than a single prophylactic dose during the surgical case. At his 2-week follow-up, he had no recurrence of his hernia and was doing well. On pathologic examination, there was no evidence of appendiceal inflammation or appendicitis. The periappendiceal fat did exhibit some fat necrosis, however, supporting the chronic periappendiceal adhesive changes.