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      Surgical management of subhepatic perforated appendicitis: a case report

      case-report

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          Abstract

          Background

          Subhepatic appendicitis is an exceedingly rare presentation, accounting for 0.01% of acute appendicitis cases. It is of prime importance to be aware of variants and manage such challenging cases accordingly.

          Case presentation

          We present a case of a middle-aged Saudi woman with subhepatic perforated appendicitis and peritonitis who underwent an exploratory laparotomy and appendectomy.

          Conclusions

          The initial diagnosis and surgical management of such patients is challenging due to an atypical presentation. The surgical management of such patients is discussed with a brief review of the literature.

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          Most cited references10

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          Laparoscopic appendectomy for appendicitis in uncommon situations: the advantages of a tailored approach.

          C Palanivelu, M. Rangarajan, R. Senthilkumar … (2007)
          Appendicitis in unusual locations or situations always poses a diagnostic dilemma and surgery is never straightforward. We aim to highlight the advantages of laparoscopy, including our own modifications, in some unusual presentations of appendicitis. We treated a total of 7,210 patients with appendicitis over 14 years from 1992 to 2006. In this study, we included patients with subhepatic appendicitis (0.08 percent), appendectomy in midgut malrotation (0.09 percent), appendicitis in situs inversus totalis (0.01 percent) and appendicitis in the lateral pouch position (0.01 percent). All patients underwent laparoscopic appendectomy. Patients with subhepatic appendicitis, appendicitis in situs inversus and appendicitis in the lateral pouch position had an uneventful postoperative course. For the patients who underwent appendectomy as part of the treatment for malrotation and the patient with the perforated subhepatic appendix, hospital stay was slightly prolonged. Most patients in our study did not have a confirmed preoperative diagnosis. Diagnostic laparoscopy through the umbilical port helped confirm the diagnosis. Port positions were then planned according to the exact position of the appendix and the technique was modified to suit each individual patient. In the surgical scenarios described here, laparoscopy is invaluable in both diagnosis and treatment.
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            Ascending retrocecal appendicitis: clinical and computed tomographic findings.

            Sooah Kim, Hyo K Lim, Ji Yeon Lee … (2016)
            To describe the clinical presentation and computed tomographic (CT) features of ascending retrocecal appendicitis. During the past 8 years, 1670 patients with surgically proven appendicitis were identified by a retrospective investigation. Thirty-three patients who underwent contrast-enhanced abdominal CT before surgery and had ascending retrocecal appendicitis at surgery were included in the patient cohort. The clinical and CT findings of these 33 patients were analyzed. Patients presented with right lower abdominal pain (49%, 16/33), right flank pain (24%, 8/33), right upper abdominal pain (18%, 6/33), and periumbilical pain (15%, 5/33). Inflamed ascending retrocecal appendices were visualized completely in 70% (23/33), partially in 21% (7 of 33), and not detected in the remaining 9% (3/33). Periappendiceal inflammatory changes were most commonly observed in the retrocolic space in 88% (29/33), followed by paracolic gutter (30%, 10/33), pararenal space (27%, 9/33), mesentery (24%, 8/33), perirenal space (18%, 6/33), and subhepatic space (3%, 1/33). Inflammatory thickening of Gerota fascia (70%, 23/33) and the lateroconal fascia (64%, 21/33) was observed as well. Perforation of the appendix with the formation of an abscess was present in 49% (16/33). The abscesses were most commonly located in the retrocolic space (88%, 14/16). Diffuse wall thickenings of the cecum (67%, 22/33) and the ascending colon (64%, 21/33) were often observed also. Appendicoliths were found in 33% (11/33). More than half of patients with ascending retrocecal appendicitis presented with atypical clinical presentation. At CT, ascending retrocecal appendicitis was associated with a high incidence of retroperitoneal inflammatory changes and appendiceal perforation.
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              Subhepatic appendicitis.

              George King (1955)
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                Author and article information

                Contributors
                Sherif Sharawy: shrifsharaway@yahoo.com
                Journal
                Journal ID (nlm-ta): J Med Case Rep
                Journal ID (iso-abbrev): J Med Case Rep
                Title: Journal of Medical Case Reports
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1752-1947
                Publication date (Electronic): 12 September 2020
                Publication date PMC-release: 12 September 2020
                Publication date Collection: 2020
                Volume: 14
                Electronic Location Identifier: 151
                Affiliations
                Department of General Surgery, Saudi German Hospital, Al-Aseer, Kingdom of Saudi Arabia
                Article
                Publisher ID: 2499
                DOI: 10.1186/s13256-020-02499-2
                PMC ID: 7488453
                PubMed ID: 32917284
                SO-VID: 7e4cabe3-3f22-418f-8cb0-6c8f97442d2a
                Copyright © © The Author(s) 2020
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                Date received : 23 July 2020
                Date accepted : 17 August 2020
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © The Author(s) 2020

                ScienceOpen disciplines: Medicine
                Keywords: subhepatic appendicitis,peritonitis,laparotomy,case report
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: subhepatic appendicitis, peritonitis, laparotomy, case report

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