Amyand's hernia is an atypical hernia, defined by the incarceration of an appendix, inflamed or not, in a hernial opening of the abdominal wall.

The first successful appendectomy through a hernial sac was performed by Amyand in 1735 in London [1].

It is a rare pathology representing 0.13% of all acute appendicitis and 1% of strangulated crural hernias according to Ryan [2].

From 1959 to 1999, thirteen cases of intra-hernial appendicitis have been reported at all sites [3]. The hernial site may be umbilical, at Spiegel's line, obturator, diaphragmatic, or even in the path of a laparoscopic trocar, but the most frequent site remains inguinal or right crural [4]. However, crural hernia is classically described in postmenopausal women with a sex ratio reaching 0.16 [5,6].

Hernia formation is usually due to the combination of abdominal hyperpressure factors (chronic cough, chronic constipation and urinary retention, abdominal obesity...) and weakening of the abdominal wall noted in cases of advanced age and obesity.

Our 54-year-old patient was obese with a BMI of 25.5 kg/height².

Concerning the pathophysiology of appendicitis, the most likely mechanism seems to be the compression of the appendix in the inextensible crural orifice with strangulation of its meso and creation of secondary ischemic phenomena [7].

The usual clinical picture of a crural Amyand hernia is often atypical making the positive diagnosis difficult [6].

Usually, it is that of a strangulated hernia without an occlusive syndrome with general signs inconsistently present [8].

According to Lawrence, the finding of local redness and warmth associated with subcutaneous crepitus of the inguinal region is usually consistent with appendicular perforation. However, no formal anatomopathological correlation exists between the intraoperative state, inflammatory or not of the appendix, and the clinical picture [6]. In our case, the patient was apyretic with a preserved general state and there were no local inflammatory signs. The biology inconstantly shows an inflammatory syndrome, the absence of which does not eliminate a local complication of the hernia (appendicitis, appendicular perforation...).

The diagnosis is very often made intraoperatively, which is the major interest of our case where the diagnosis was made radiologically preoperatively.

In a series of 60 Amyand's hernias published by Weber, the diagnosis was made preoperatively in only one patient [9].

In a recent Turkish series published in 2009 of 1090 children with inguinal hernias, 33 of these were incarcerated and 12 patients had a Claudius Amyand hernia. These were always boys with a median mean age of 40 days (extreme than one day 14 months) [20, 21]. Among the 12 Claudius Amyand hernias, two appendages were normal, six were inflammatory and two were the site of serous inflammation of uncertain significance, mechanical or infectious. Several cases of left-sided Claudius Amyand hernia have been reported.

In Inan's series, three of the eleven published patients had abdominopelvic CT scans, which made the diagnosis in only one [8-16]. The low use of imaging preoperatively may be explained by the low incidence of the disease [6-15]. In case of suspected acute intrahernial appendicitis, an ultrasound [10-14] or computed tomography (CT) scan [11] should be performed to assess the condition of appendix, its length, the position of the cecum and thus determine the determine the surgical approach and technique.

Our patient had an ultrasound of the inguinal region which evoked the diagnosis. The use of imaging is justified in our case because of the diagnostic doubt and with a view to eliminating other probable diagnoses (adenophlegmon, tumor, aneurysm of a femoral artery, etc.).

For CT, the use of multiplanar reconstructions greatly facilitates the diagnosis. [18].

The positive diagnosis is most often made intraoperatively when a vermicular appendix is found within the hernia sac, whether it is inflamed or not. The operation consists of an appendectomy and resection of the hernia sac [17-19].

Management is always surgical. Most authors recommend an inguinal appendectomy [8]. If the appendicitis is complicated by a perforation with peritonitis, a laparotomy by median approach or by Mc Burney should be performed [3,8].

The cure of the crural hernia is usually done by simple raphia according to the Mc Vay technique [12]. The use of a synthetic prosthesis should be avoided, as according to several authors it increases the risk of postoperative infection [8,12,13]. The immediate and secondary postoperative follow-up is generally simple if the diagnosis is made early and the surgical treatment is undertaken in time [3,6,8,13].