Discussion and Conclusions
The annual incidence rate of subhepatic appendicitis is approximately 0.09 per 100,000 populations [2]. Incomplete rotation and fixation of the intestine due to a defect in fetal gut rotation results in a subhepatic caecum and appendix. [9]. This being a very rare phenomenon. The earliest review of subhepatic caecum and appendix has been documented in 1863 in a review of by King in 1955.[3] Often mimicking of hepatobiliary or gastric disease clinically is seen in subhepatic appendicitis resulting in a delay in diagnosis.[1, 7]. This results complications such as sepsis, suppuration, and perforation [2]. Radiologic imaging thereby is of prime importance in identifying such anomaly. Due to the availability and ease to perform ultrasound may be the preferred first-line screening modality. High suspicion and caution must be maintained in atypical presentations due to reports where subhepatic appendiceal disease was misdiagnosed as liver abscess or cholecystitis [1, 2]. In our case the abdominal ultrasound showed subhepatic fluid collection and inability to visualize the appendix. Computed tomography(CT) of the abdomen and pelvis provides high sensitivity (100%), specificity (95%), and accuracy (98%) in identifying acute appendicitis.[10] In our patient, CT scan delineated subhepatic perforated appendicitis with a subhepatic and pelvic collection. The appendix also contained a fecolith.
In a subhepatic appendix a conventional Lanz incision in the right lower quadrant may not be suitable to remove the appendix. In our case we performed a midline laparotomy due to subhepatic location of the appendix and the possibility of retrocecal, dense adhesions or fibrosis and perforation which would make a laparoscopic approach an unsafe option. In addition to the fact that open access would provide better tactile input and direct access to the appendix. laparoscopy could also be an option in patients who are clinically stable and not peritonitic in a similar situation for its versatility, diagnostic, and therapeutic ability [7]. If one were to proceed laparoscopically steps which would be beneficial include using an angled laparoscope for better viewing, initial mobilization of the cecum, using an extra port for better access, twisting of the appendix making dissection easier. In conclusion, subhepatic appendicitis is a rare presentation and as surgeons one must be cognizant of the atypical presentation, and surgical modalities.