Acute Appendicitis By Domingo

Presenting T. Alvear

and Morton

as a Scrotal Mass M. Rayfield

THE OCCURRENCE of acute appendicitis in an inguinal hernia in chil1 dren is unusual and rupture of the appendix into the testicle, causing an as a scrotal mass or an acute hydrocele, is most acute orchitis manifested uncommon. CASE

REPORT

A 5-yr-old male was admitted because of a painful right scrotal mass. This mass was noted by his mother 2 mo prior to admission. The mass was described as sudden in onset, associated with pain in the right scrotal area, and aggravated by walking. This was not accompanied by genitourinary symptoms nor gastrointestinal complaints. A local physician was consulted, and he diagnosed the lesion as a hydrocele. The pain and swelling improved in time; however, local tenderness persisted. A surgical consultation was obtained 6 wk later. At that time a thickened right spermatic cord and a tender, enlarged right testicle measuring approximately 3 x 6 cm was found. On standing, the right groin appeared fuller than the left groin. The entire right scrotum was swollen to about five to six times its normal side when compared with the left side. He was scheduled for elective admission: however, be developed measles. He was finally admitted 2 wk later. At that time, there was no change in the physical findings. The laboratory data included a hemoglobin of 10.4 g, hematocrit of 30%, and WBC of 7100/ cu mm, with 38 neutrophils, 2 stabs, 52 lymphocytes, 4 monocytes, and 4 eosinophils. Platelet count was normal. SMA 12 and SMA 6 studies were normal except for slight elevation of alkaline phosphatase. The chest roentgenogram and urinalysis were normal. At exploration, the appendix was found in the hernia sac and had perforated at its tip, causing an acute orchitis (Fig. I). The tip of the appendix was adherent to this swollen testicle, and it could only be detached by sharp dissection. The testicle measured approximately 3 x 6 cm, and was quite edematous. Appendectomy was carried out with inversion of the stump. Herniorrhaphy was performed by high ligation of the sac with 3-O silk, and wound closure was accomplished with 4-O chromic catgut. Pathologic section of the distal tip of the appendix showed marked serosal thickening with fibrous organization and cellular response of both acute and chronic type. The hernia sac likewise showed acute and chronic organizing inflammatory response.. The patient was given intravenous cephalothin, 500 mg intraoperatively, and was continued on this postoperatively at a dose of 500 mg every 6 hr for 72 hr. The patient has an uneventful recovery and was discharged on the third postoperative day. Followup revealed primary healing of the inguinal wound without any evidence of infection. The right testicle returned to it normal size. DISCUSSION

The most recent review of acute appendicitis occurring in inguinal hernias was done by Carey in 1967.’ Six of his cases were in indirect inguinal hernias, and three were found in femoral hernias, and one in an incisional hernia. In 1937 Ryan collected 537 cases in which the appendix was found in a hernia? He stated that the incidence of acute appendicitis in a hernia was 0.13% of all acute appendicitis. In 1974 Voitk et al. reported two cases of ruptured apFrom the Department of Surgery, Polyclinic Hospital. Harrisburg, Pa. Address for reprint requesis: Domingo T. Alvear. M.D., Uptown Professional Bldg., 2645 N. 3rd St.. Harrisburg, Pa. I71 IO. 0 1976 by Grune & Stratton. Inc. Journal of Pediatric Surgery, Vol. 11, No. 1 (February), 1976

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pendicitis in femoral hernias and reviewed the literature in regard to the subject3 In most of these reports, acute appendicitis in a hernia (inguinal or femoral) occurs in past middle-age, and we can only find one case reported in the literature in which it occurred in a child. This was in a 6-wk-old infant who presented with a swollen right scrotum that was extremely tender.4 A gangrenous appendix was removed without inversion of the stump. This patient died on the second postoperative day. Most of the patients described in the literature presented with a tender groin or scrotal mass, tenderness and rigidity in the right lower quadrant, with occurrence of pain in intermittent attacks with intervals of comfort, and the presence of fever and leukocytosis. No report can be found associating acute orchitis with hernial appendicitis as in our case. Our patient probably had a focal appendicitis involving the tip, which ruptured and was confined by the tunica vaginalis and the tunica albuginea. The patient’s body defenses probably confined the infection to this area and resolved the abscess spontaneously, since there was no pus encountered during the operation. This can also explain the absence of complications in spite of the 2-mo delay for the operation. If we had seen this patient during the occurrence of the initial complaint, he probably would have been operated on immediately, and the differential diagnosis would have been either a strangulated hernia or testicular torsion. ACKNOWLEDGMENT The authors wish to thank Leonard W. Konikiewicz, ment, Polyclinic Hospital, for his assistance in obtaining

Director of the Audio Visual and preparing the photograph

Departof the

case presented.

REFERENCES 1. Carey LC: Acute appendicitis occurring in hernias: A report of 10 cases. Surgery 61:236, 1967 2. Ryan WJ: Hernia of the vermiform appendix. Ann Surg 106:135. 1937 3. Voitk AJ, MacFarlane JK, Estrada RL:

Ruptured appendicitis in femoral hernias. Ann Surg 179:24, 1974 4. Burger TO, Torbert HC: The diagnosis of acute hernial appendicitis. Am J Surg 42:429, 1938

Acute appendicitis presenting as a scrotal mass.

Acute Appendicitis By Domingo Presenting T. Alvear and Morton as a Scrotal Mass M. Rayfield THE OCCURRENCE of acute appendicitis in an inguinal he...
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