AMYAND’S HERNIA : CASE STUDY AND REVIEW OFLITERATURE Venkata K Kella M.D, Srinivas Kavuturu M.D, I. Mukherjee M.D*, V.R.Vattipally M.D, Bala GR Thatigotla M.D, Daniel Farkas M.D, FACS, John M Cosgrove M.D, FACS Department of Surgery, Bronx Lebanon Hospital, Bronx, New York NY 10457* Amyand's hernia, the presence of appendix in the inguinal hernial sac, is a rare condition and accounts for about 1% of all inguinal hernia. Acute appendicitis is much less common in this situation and few case reports are found in literature. We present a case of acute appendicitis with in the incarcerated right inguinal hernia, diagnostic, management considerations and review of the literature. INTRODUCTION Claudius Amyand, surgeon to King George II, performed the first successful appendectomy in 1735, on a 11 year old boy with perforated appendicites in the inguinal hernial sac. The incidence of non inflamed appendix in a hernial sac is 1% and appendicites in hernial sac is 0.1%. The age of presentation ranges from 5 weeks premature to 89 years, with bimodal distribution at extremes of age.  Primarily presents in the right groin. Can also occur on the left side due to situs inversus, mobile cecum, malrotated gut. Pathogenesis: 1) external compression of appendiceal lumen by internal ring, exacerbated by increased abdominal pressure. 2) Inflammatory adhesions of routine appendicitis. 3) Inflammatory edema of the tissues contribute to incarceration of the inguinal hernia.  Presenting symptoms are similar to incarcerated hernia i.e tender painful inguino scrotal swelling, groin abscess.Fever and leukocytosis are not often present because of sequestration of inflammatory process with in the hernial sac. Rarely diagnosed preoperatively. CT Scan remains an integral part of preoperative diagnosis of Amyands hernia, as in our case.   Differential diagnosis include incarcerated, strangulated hernia, Torsion of testis, epididymitis and acute hydrocoele.  Treatment of Amyand's hernia is NPO, IV hydration, Intravenous antibiotics, transhernial appendectomy and herniorraphy with out mesh. In late stage presentation, simple drainage of abscess followed by interval herniorraphy. DISCUSSION: 43 year old male, with no medical co morbidities, presented with painful swelling of right groin of 1 week duration, which, he noticed it after lifting weight, associated with nausea and vomiting. Physical examinaton revealed stable vital signs and tender, non-erythematous, partly reducible right inguinal hernia. Laboratory tests were normal. CT scan of abdomen with contrast revealed inflamed appendix with appendicolith in the right inguinal hernial sac. Exploration of right groin confirmed dilated and inflamed appendix in the hernial sac. Appendectomy was performed and peritoneum was closed. Modified Bassini’s hernia repair was performed, without a mesh. Patient received cefoxitin in the perioperative period.  His post operative recovery was uneventful. Follow-up at 3 months, the patient remained well. CASE STUDY CT scan of abdomen revealing appendicolith, appendicites in the right inguinal hernial sac Amyand’s hernia is rare and can easily be misdiagnosed as incarcerated or strangulated hernia. Pre operative imaging is helpful, as in our case, in differentiating the condition, but is rarely performed. Proper treatment involve appendectomy through herniotomy and primary repair of hernia with out mesh.   CONCLUSION: Operative picture showing inflamed appendix (Left) and Bassini repair (Right) REFERENCES: Review article- appendicitis in groin hernias. J Gastrointestinal Surg 2007, 11:1368-1372. Left sided amyand’s hernia Singapore Medical Journal 2005; 46(8):424 Acute appendicites in an Incarcerated inguinal hernia Journal of National Medical association Vol 93, No12, December 2001.