Acute appendicitis in a patient with sub-hepatic, sub-serosal, and retroperitoneal location. An intraoperative management challenge.

INTRODUCTION

Appendicitis in patients with a sub-hepatic and retroperitoneal position is rare, often leading to delayed diagnosis and management due to its atypical presentation. A high index of clinical suspicion and the use of imaging modalities can improve the outcomes of patients with sub-hepatic appendicitis.

CASE PRESENTATION: A 20-year-old male presented with 36 h duration of right-sided abdominal pain, accompanied by nausea, vomiting, anorexia, and fever. He exhibited tachycardia and right lower quadrant abdominal tenderness. Laboratory tests revealed leukocytosis with a left shift and ultrasound showed simple appendicitis. An open appendectomy revealed a retroperitoneal, sub-hepatic, and sub-serosal inflamed appendix. The patient's postoperative course was uneventful.

CLINICAL DISCUSSION: Sub-hepatic position of the appendix is rare accounting for 0.08 % of all cases of acute appendicitis. It is associated with mid-gut mal-rotation or arrested cecal descent during embryogenesis. Patients with sub-hepatic appendicitis usually have atypical presentation mimicking hepatobiliary pathologies which will lead to a delayed diagnosis and management. The standard management of sub-hepatic, retroperitoneal, and sub-serosal appendicitis relies on a laparoscopic approach however in case of difficulty and resource limitation, open appendectomy is the ultimate option.

CONCLUSION

Sub-hepatic retroperitoneal and sub-serosal appendicitis, though rare, should be included in the differential diagnosis for patients with atypical abdominal pain. A high index of clinical suspicion, use of imaging modalities, and meticulous dissection with adequate exposure are crucial for a successful outcome.