Delayed Diagnosis of Inguinal Hernia With the Appendix Strangulated

This case involves a fifty-year-old female who presented to the emergency department with generalized abdominal pain and distention.  The patient’s family stated that she had not had a bowel movement in two days and had never experienced similar symptoms. The patient was admitted to the hospital for observation, and to wait on imaging results, but no intervention was sought immediately. The distention and pain increased progressively until the patient’s mental status deteriorated, and she was rushed to the OR for an emergent exploratory laparotomy. The patient was found to have an obstructed bowel and an incarcerated Amyand’s hernia.

Question(s) For Expert Witness

  • 1. How could this complication have been avoided?

Expert Witness Response E-000320

Reported conditions in patients presenting with incarcerated Amyand’s hernias include mucocele of the appendix associated with coexisting colon cancer, fecaliths of the appendix with coexisting colonic diverticulitis, adenocarcinoma of the appendix, and inguinal appendicocele with pseudomyxoma peritonei. A high index of suspicion accompanied by CT scans can avoid delays in management by helping the detection of any coexisting conditions and the planning of the most appropriate procedure, thereby improving patient outcomes. CT scans, while helpful, must not delay surgical consultation or intervention in critically ill patients with a surgical abdomen. The most important aspect of surgical intervention in Amyand’s hernia is to limit any septic spread that can result from perforation of the appendix. Once the septic process involves the peritoneum, it becomes more difficult to manage and is associated with increased mortality.


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