Medical Rarity: Premature Baby Survives Emergency Surgery for Perforated Appendix in Scrotum

Some medical cases are so rare they challenge even the most experienced surgeons. When an extremely premature neonate weighing just 980 grams developed an incarcerated hernia with a perforated appendix extending into the scrotum—a condition known as Amyand’s hernia—the surgical team at Burjeel Hospital, Abu Dhabi, faced a life-threatening emergency requiring immediate intervention and extraordinary skill. 

The Premature Journey 

Birth Statistics: 

• Gestational age: 27 weeks (extremely premature) 

• Birth weight: 930 grams (approximately 2 pounds) 

Initial Complications: 

• Severe Respiratory Distress Syndrome (RDS) 

• Invasive mechanical ventilation for 2 weeks 

• Surfactant therapy required 

• Hemodynamically significant Patent Ductus Arteriosus (PDA) 

• PDA closed on day 6 

• Electrolyte imbalances 

The Sudden Crisis 

Around 3 weeks of age (weight: 980 grams), the baby developed alarming new symptoms: 

• Significant abdominal distension 

• Rising inflammatory markers 

• No obvious intestinal obstruction 

• Swelling noticed in right scrotum 

Immediate concerns: 

• Possible testicular torsion? 

• Incarcerated hernia? 

• Acute surgical emergency? 

Diagnostic Investigation 

Abdominal X-rays: 

• Distended bowel loops 

• No signs of intestinal perforation 

Ultrasound findings: 

• Normal testis with good vascularity (ruling out torsion) 

• Incarceration of “intestinal loop” 

• Unexpected finding requiring emergency surgery 

The Shocking Intraoperative Discovery 

Emergency right inguinal exploration revealed a medical rarity: 

Amyand’s Hernia with Perforated Appendix 

• The appendix had herniated into the inguinal canal 

• The appendix was perforated 

• Extension into the scrotum 

• Right testicle was unaffected 

Immediate Surgical Response: 

1. Perforated appendix removed via inguinal incision 

2. Stump closure performed 

3. Abdominal exploration: no contamination found 

4. Hernia repair completed 

Surgery Details: 

• Patient tolerated procedure well 

• Returned to NICU for post-operative care 

• Minimal complications 

Understanding Amyand’s Hernia 

What is Amyand’s Hernia? 

• Extremely rare condition 

• Appendix herniated into inguinal canal 

• Named after Claudius Amyand (1735 – first documented repair) 

• Occurs in less than 1% of inguinal hernias 

Classification: 

• Type 1: Normal appendix in hernia 

• Type 2: Acute appendicitis within hernia (this case) 

• Type 3: Acute appendicitis, peritonitis 

• Type 4: Acute appendicitis with other abdominal pathology 

Why So Rare in Neonates: 

• Inguinal hernias common in premature infants 

• Appendix in hernia extremely uncommon 

• Perforated appendix in hernia exceptionally rare 

• In extremely premature neonate: nearly unprecedented 

The Surgical Challenges 

1. Extreme Prematurity 

• 27-week gestational age 

• Only 980 grams body weight 

• Tiny anatomical structures 

• Fragile tissues 

2. Inflammatory Tissue 

• Perforated appendix caused inflammation 

• Obscured normal anatomy 

• Increased bleeding risk 

• Made dissection challenging 

3. Diagnostic Difficulty 

• Abdominal distension without clear obstruction 

• Scrotal swelling: multiple differential diagnoses 

• Ultrasound showed “intestinal loop”—actually appendix 

• True diagnosis only confirmed intraoperatively 

4. Anesthesia Complexity 

• Extremely premature with respiratory disease 

• Previous ventilation dependence 

• Careful hemodynamic management 

• Coordination between anesthesia and neonatology teams 

5. Surgical Expertise Required 

• Pediatric surgical subspecialty training 

• Experience with extremely premature infants 

• Ability to adapt intraoperatively 

• Skill in neonatal hernia and appendix surgery 

The Multidisciplinary Response 

Anesthesia Excellence: 

• Dr. Hala Mohamed Hamada (monitoring and sedation) 

• Dr. Samer Shouman Alkahwaty (airway and ventilation management) 

• Excellent coordination with surgical and neonatal teams 

Neonatal Expertise: 

• Dr. Shabeer Panangandy (pre-operative optimization) 

• Post-operative NICU management 

• Long-term developmental follow-up 

Surgical Precision: 

• Prof. Dr. Amulya Saxena (leading pediatric surgery and management) 

• Adapted approach based on intraoperative findings 

• Minimized surgical trauma 

• Complete removal of infected tissue 

Post-Operative Course 

Hospital Recovery: 

• Unremarkable post-operative course 

• Continued NICU care for prematurity 

• No surgical complications 

• Stable condition within 3 weeks 

Discharge: 

• Discharged in stable condition 

• Appropriate weight gain 

• Normal feeding 

• Surgical site healed well 

Histology Confirmation: Appendix showed: 

• Mucosal ulceration 

• Infiltration by polymorphonuclear leukocytes 

• Markedly congested blood vessels 

• Focal necrotic appendiceal wall 

• Neutrophil collection, intravascular fibrin 

• Inflammation extending to serosa 

• Confirmed diagnosis: Perforated appendicitis 

Why This Case Matters 

1. Medical Rarity 

• Amyand’s hernia: <1% of all inguinal hernias 

• In extremely premature neonate: nearly unreported 

• With perforation: exceptional rarity 

• Adds to medical literature and knowledge 

2. Surgical Excellence 

• Demonstrates advanced neonatal surgical capability 

• Showcases multidisciplinary teamwork 

• Proves complex procedures possible in UAE 

• Avoids need for international transfer 

3. Positive Outcome 

• Baby survived and thrived 

• No long-term complications 

• Normal development expected 

• Family kept together during crisis 

4. Diagnostic Acumen 

• Recognized emergency despite unusual presentation 

• Appropriate urgent intervention 

• Correct surgical approach 

• Prevented potential catastrophe 

Long-Term Prognosis 

After successful repair: 

• Normal development expected 

• No appendix-related issues (removed) 

• Hernia repaired—no recurrence expected 

• Follow-up for prematurity-related concerns only 

• Excellent quality of life anticipated 

Our Experts 

Expert Neonatal Emergency Care 

Rare and complex neonatal surgical emergencies require immediate access to specialized expertise. Our multidisciplinary team provides 24/7 emergency neonatal surgical care. 

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