Laparoscopic management of subhepatic appendicitis

Acute appendicitis is one of the most common causes of acute abdomen that requires an emergency surgical approach. Acute appendicitis usually presents with diffuse pain that starts from the periumbilical area and localizes to the right lower quadrant. However, the clinical features might differ if the locations of the appendix change in the abdomen.
A 25-year-old male patient presented to the emergency department with a complaint of right upper quadrant pain for two days and clinical signs similar to acute cholecystitis. On his first physical examination, there was tenderness in the right upper quadrant. White blood cell count levels and neutrophil levels were elevated on blood test results. He was considered for acute cholecystitis after the first evaluation, and hepatobiliary ultrasonography was performed. The liver parenchyma and the biliary tract structures were shown to be non-pathological on ultrasonography (USG). Thus, computed tomography (CT) of the whole abdomen was planned and performed. It demonstrated the upper location of the cecum and subhepatic appendix. Inflammatory signs were detected on the appendix wall and surrounding tissues on the CT scan. Thereupon, emergency surgery was planned, and a laparoscopic appendectomy was performed.
The subhepatic location of the appendix is reported as extremely rare, with a rate of approximately 0.08% of all appendicitis cases. This clinical presentation was first reported in 1955 by King. This rare anatomic variation may cause delayed diagnosis and treatment difficulties. Subhepatic appendicitis can mimic hepatobiliary, gastric, or renal disorders like acute cholecystitis, hepatic abscess, perforated duodenal ulcer, and right nephrolithiasis.