eP136 - An Unanticipated Encounter: A Case Report of Coexisting Cecal Adenocarcinoma with an Amyand’s Hernia

Purpose/Background: This is a case of a 71-year-old male with an inguinal hernia containing perforated appendicitis and a cecal adenocarcinoma treated with an open right inguinal hernia repair with ileocecectomy. Amyand's hernia is a rare type hernia in which the hernia sac contains the appendix, accounting for < 1% of all inguinal hernias.(1) The incidence of acute appendicitis within this hernia ranges from 0.13 to 0.8%.2 Concurrent cecal adenocarcinoma within the sac is seldom documented.(3) There is currently no standardized treatment of Amyand's hernias.(4,5,6) Current approaches include open and laparoscopic surgical repair of the hernia, with or without removal of the appendix.Methods/Interventions: A 71- year- old male presented with six weeks of decreased appetite and weight loss. A computed tomography of the abdomen pelvis demonstrated an indirect right inguinal hernia containing perforated appendicitis and a 7.9 x 7.3 x 7 cm rim-enhancing collection inseparable from the base of the cecum (IMAGE 1). The patient was not a candidate for percutaneous drainage of this scrotal abscess so the decision was made to proceed with operative intervention. An inguinal incision was made and an indirect inguinal hernia sac was identified and entered. The appendix and ileocecal junction were delivered into the operative field. Due to the presence of phlegmonous changes to the hernia sac, appendix, and cecum making appendiceal base inseparable from cecum , an appendectomy with ileocecectomy was performed with a subsequent primary stapled ileocolonic anastomosis. A primary tissue repair was performed using Shouldice technique and a drain was left in place. Surgical pathology demonstrated a 10.5 cm invasive poorly-differentiated cecal adenocarcinoma extending to the serosal surface with negative margins and lymph nodes, stage IIa. Postoperative course was complicated by a persistent abscess (IMAGE 2). A scrotal ultrasound performed one month after discharge exhibited no residual collection.Results/Outcomes: Case report, see MethodsConclusion/

Discussion: Due to the rarity of Amyand hernias, even more so those that involve cecal adenocarcinoma, it remains pertinent to discuss the presentation and treatment as there is no current standardized treatment. A thorough history and exam must be performed and a CT scan including the bilateral scrotum. For perforated Amyand hernias, consider initial non-operative management and advance to open inguinal hernia repair with appendectomy if needed. If managed non-operatively, older patients are recommended to undergo colonoscopy after treatment to assess for malignancy. Treatment of Amyand's hernia should be individualized based on the patient's age and comorbidities, the severity of the hernia, and the potential for malignancy. Future studies should focus on the outcomes associated with the use of mesh, the utility of prophylactic appendectomies when no appendicitis is present, and laparoscopic versus open. The rarity of this condition may make a high powered study of these topics difficult."IMAGE 1: CT Scan of abdomen and pelvis on day of presentation

IMAGE 2: CT Scan of abdomen and pelvis on hospital day 7
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