Claudius Amyand hernia (CAH) is defined by the presence of a normal or inflammatory vermiform appendix within a hernial sac, often inguinal [1] . It is a very rare entity in children. It was first described by Claudius Amyand in 1735 at St. George’s Hospital in London in an 11-year-old child who was admitted for a right inguinal hernia complicated by a right scrotal stercoral fistula. Amyand discovered a pin within the stercolith during exploration through a right inguinal incision. He performed an appendectomy with resection, closure of the hernial sac and flattening of the fistula. The postoperative course was simple [2] . The definitive diagnosis of this condition is intraoperative in the vast majority of cases. We report 2 cases of Claudius Amyand hernia (CAH) in children discovered incidentally during surgery in a pediatric surgical setting in Guinea Conakry and through our cases, we will discuss the epidemiological, diagnostic and therapeutic aspects of this condition with a review of the literature.

HCA is an extremely rare pathology in children [3] , despite this rarity, all ages are affected from 3 weeks to 92 years . The clinical presentation is often that of a strangulated inguinal hernia [1] [5] and frequently encountered in boys and the right side is more affected [2] as is the case in our two observations; however the rare cases on the left reported in the literature could be linked to situs inversus, intestinal malrotation, a mobile cecum or a very long appendage [4] .

Preoperative diagnosis is rare in current practice because of the obvious indication for surgery in a picture of strangulated inguinal hernia [6] . To diagnose CAH in the face of a picture of incarcerated or strangulated hernia, some authors request an inguinal scrotal ultrasound; however, the ultrasound does not always allow discrimination of intestinal loops from an inflamed appendix. This imprecision makes diagnosis difficult and leads to diagnostic errors. Laermans et al. have shown that the combination of CT and multiplanar reconstruction is the most effective technique to better visualize the appendix and its relationships with surrounding structures, thus helping to establish with certainty the correct preoperative diagnosis [3] . CT scanning is not systematically used in cases of clinical suspicion of a complicated hernia [7] .

Balthazar, Atema and Stoma showed a significant superiority of CT scanner compared to ultrasound according to Dobos et al. . Stroman in a study on 107 patients mentions a sensitivity of 30% for ultrasound against 92% for CT scanner . Inan et al. [6] diagnosed through CT scan in one of their patients the presence of the appendix in the inguinal canal, thanks to the scanner ( Figure 7 ). In addition, some authors propose that a CT scan be systematically performed when developing a strangulated hernia, as well as an exploratory laparoscopy for diagnostic and curative purposes. This coelioscopy would avoid reinterventions burdened with high morbidity and mortality . CT scan and coelioscopy are examinations that are not within the reach of the majority of our patients, given their cost in our context. Health insurance for all and awareness among our doctors could change this situation in our work context.

The positive diagnosis of Claudius Amyand hernia is made intraoperatively upon observation of a vermicular appendix located within the hernial sac, whether it is inflamed or not [2] . Both of our observations were discovered incidentally during the operation; ultrasound and CT scans were not performed. When we went to the operating room, we did not think of a Claudius Amyand hernia, it was during the operation that we were faced with the evidence. Surgical exploration of our first patient had revealed a large long appendix within the hernial sac, strongly adhering to the latter as well as the cecum, a part of the terminal ileum; in the second patient, the appendix was very inflamed, located in the hernial sac with its cecum and a part of the terminal ileum, with intestinal distress. In both cases, there was a defect in the attachment of the proximal ascending colon. Colonic and cecal attachment defects and a long appendix have been described by some authors as factors favoring HCA [3] [4] . In our cases, abdominal hyperpressure would have led to the unfixed cecum with the appendix in the persistent peritoneo-vaginal canal.

The presence of the appendix in the hernial sac predisposes to the development of adhesions between its serous membrane and the hernial sac, resulting in an irreducible hernia. Compression of the prolapsed appendix in the hernial sac and adhesions could lead to perforation of the appendix [3] [4] ; in case of spontaneous reduction of a strangulated hernia or by taxis on CAH, the patient could develop an abdominal complication in the postoperative period, as reported by Dobos et al. [7] in their study. Among incarcerated hernias containing viscera, the presence of the appendix is estimated at 1%. The development of acute appendicitis inside a hernial sac of CAH hernias is estimated at 0.13% of all appendicitis. Despite this rarity, it is a pathology that, in the event of delayed diagnosis, can be complicated by appendicular abscess or peritonitis, thus putting the patient’s life at risk [6] . Our second patient therefore presented with appendicitis due to a Claudius Amyand hernia.

The practical approach to CAH depends on the appearance of the vermiform appendix in the hernial sac and the clinical picture . Appendectomy by inguinal herniotomy followed by closure of the peritoneovaginal canal is the ideal treatment for uncomplicated Claudius-Amyand hernia. Subumbilical laparotomy associated with herniotomy is necessary in complicated cases. Appendectomy in the hernial sac through the right lower abdominal crease approach was performed in our patients, followed by closure of the sac. The classification of Lossanoff and Basson into four types [7] in 2008 codified the therapeutic attitude of Amyand’s hernia, this classification was modified by Rikki into five types ( Table 1 ) [3] . Our two clinical cases can be classified as type 1 for the 1st case and type 5b according to the Rikki classification of Claudius D’Amyand hernias. It should be noted that in children, the use of prostheses is prohibited in cases of CAH. Appendectomy and closure of the peritoneo-vaginal canal are the procedures to be carried out simply in children. In reality, this classification is not adapted to children.

This latter classification does not take into account left CAH for which a preventive appendectomy is recommended because, in case of future appendicitis, there is a high risk of diagnostic delay [3] . Laparoscopic reduction has also been described in the literature . We compare the diagnostic aspects and therapeutic attitude of our patients according to the characteristics of the appendix with those of some authors in Table 2 . In this table, we note that all authors are doing appendectomy followed by closure of the hernia sac in children.

RSISH: Right strangulated inguinal scrotal hernia; RISH: Right inguinal scrotal hernia; IH: Inguinal hernia; M: Male.

Claudius Amyand hernia most often presents in children incidentally during the repair of an incarcerated or strangulated right inguinal hernia. Since preoperative diagnosis is rare, the systematic use of CT scans for strangulated hernias in children and exploratory laparoscopy for diagnostic and curative purposes would help avoid diagnostic errors. The reduction of strangulated hernias, especially on the right, under anesthesia or by taxis in children must be carefully considered to avoid missing a Claudius Amyand hernia with its abdominal complications, such as appendicular peritonitis, which can be life-threatening for the child.

The first patient in this article was entrusted to us by our dear master Professor Mamady Keita and was treated free of charge thanks to him. We extend our sincere thanks to him for this mark of confidence. It should be remembered that he accepted us into his pediatric surgery department at the Donka National Hospital more than 15 years ago and made us love pediatric surgery; he also gave his blessing during our specialization. All our gratitude, dear master, may God keep you in good health for a long time.