Subhepatic perforated acute appendicitis in a patient with midgut malrotation: A case report and review of the literature

Anatomical Variations of the Vermiform Appendix

OBJECTIVE

The aim of the present work is to systematically review and present the existing literature on anatomical variations of the appendix.

METHODS

Detailed research was conducted in the PubMed medical database, using the terms "Appendix" AND "Anatomical variations", and 74 articles were initially revealed. After the application of the inclusion and exclusion criteria, all the non-related articles were excluded, and thus 40 articles were finally selected.

DISCUSSION

The data analysis suggests that the location and form of the appendix may significantly vary among individuals. Common anatomical variations concerning its location include retrocecal, pelvic, retro-ileal, pre-ileal, prececal and paracecal appendices. The first two variants are the most common, although there is a discrepancy regarding their exact incidence. Rarely, the appendix may be intracecal, intramural, subhepatic or located in the left abdomen; mismatches of the McBurney guide point with the base of the appendix are also recorded. Concerning the appendix's form, several variations in the length, diameter, shape and number of appendages (doubling, tripling) may be present.

CONCLUSIONS

As evident from the presentation of the results, the vermiform appendix presents a wide variety and number of anatomical variations. The latter are of particular clinical importance and should be known to doctors - especially surgeons - to avoid complications in clinical practice.

Malrotated subhepatic caecum with subhepatic appendicitis: Diagnostic dilemma: A case report

INTRODUCTION

Acute appendicitis is among common surgical emergency. Subhepatic appendicitis is rare and difficult to diagnose and manage. There are few case reports across the world.

CASE PRESENTATION

We presented a case of 7 year's old child with no known medical illness presented with acute onset vague abdominal pain experienced for three days. he was symptomatically treated as Acute gastroenteritis and dyspepsia later diagnosed with acute appendicitis and underwent laparotomy. He has malrotated subhepatic cecum with Subhepatic gangrenous appendicitis Open appendectomy done and discharged improved.

CLINICAL DISCUSSION

Subhepatic appendicitis is a condition where the appendix is abnormally located in the upper right abdomen. This atypical placement often leads to delayed diagnosis and complications due to its similar symptoms to other abdominal diseases. While ultrasound is a valuable tool for diagnosis, laparoscopic appendectomy is the preferred treatment method when available. However, in resource-limited settings without laparoscopic capabilities, open surgery is necessary.

CONCLUSION

Subhepatic appendicitis is a rare occurrence and its infrequent location makes it difficult to diagnose. Awareness of various location of appendix, a high index of suspicion and radiological imaging is required for prompt diagnosis and management. Appendicitis in subhepatic appendix and high up cecum creates a lot of confusion in both diagnosis and surgical exploration which may lead in complication and delay in treatment.

An International Consensus Survey among Pediatric Surgeons on the Role of Appendectomy in Malrotation

Introduction

Ladd's procedure, originally described in 1936 for the treatment of malrotation, does not traditionally include appendectomy as a standard step. We conducted a multinational survey to investigate the current consensus on the role of appendectomy in Ladd's procedure.

Methodology

An anonymous online survey was distributed to pediatric surgeons worldwide. The survey collected demographic data and explored surgical preferences related to the management of malrotation. Open-ended questions were used to assess the opinions regarding the necessity of appendectomy, decision-making factors, and complications associated with appendectomy during Ladd's procedure.

Results

A total of 343 responses were received from 46 countries. Of the respondents, 319 (93%) were consultants and 24 (7%) were residents/trainees. When asked about the choice between open and laparoscopic Ladd's procedure, 292 (85%) preferred open surgery. Overall, 184 (53%) respondents favored appendectomy in both open and laparoscopic Ladd's procedure. Furthermore, 172 (50%) surgeons advocated for appendectomy in all malrotation cases, citing concerns about potential future appendicitis. While differences existed between all comparisons, none of them reached statistical significance. The factors influencing the decision to preserve the appendix included the risk of postoperative complications and the potential future use of the appendix as a surgical conduit. The surgical complications following appendectomy included surgical site infections in 14 (33%) patients, adhesive obstruction in 13 (31%) patients, intrabdominal abscesses in 10 (24%) patients, and fecal fistulas in 5 (12%) patients.

Conclusion

The majority of surgeons aim to perform appendectomy in all malrotation cases, considering the potential risks and benefits of this approach. These findings offer valuable insights for clinical practice and may inform future guidelines and decision-making algorithms.

Complicated appendiceal diverticulitis a extremely rare cause of acute abdomen: A case report and literature review

INTRODUCTION AND IMPORTANCE

Appendiceal diverticulitis (AD) represents a rare cause of acute abdomen. Diagnosis of AD is a challenge because of its rarity and resemblance to other ileocecal diseases like as cecal diverticulitis (CD) and acute appendicitis (AA). Preoperative imaging can be useful to aid diagnosis. Surgery represents the correct treatment of AD.

CASE PRESENTATION

A 48-year-old Caucasian male presented to the Emergency Department with a two-day history of right lower quadrant (RLQ) abdominal pain and fever. Physical examination revealed RLQ abdominal pain and rebound tenderness with muscle guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal computed tomography(CT) scan showed findings of AA and a thin-walled 5 mm appendiceal diverticulum. The patient underwent laparoscopic appendectomy. The postoperative course was uneventful, the patient was discharged on the 5th postoperative day in a stable condition. Gross anatomy confirmed the presence of appendiceal diverticulum in the distal appendix on the mesenteric border. Histopathological examination revealed an inflamed and perforated appendiceal pseudo-diverticulum with surrounding AA and peri-appendicitis.

CLINICAL DISCUSSION

Appendiceal diverticulosis is an uncommon entity, classified as congenital or acquired based on the number of appendiceal layers herniating through the normal wall. Two thirds of diverticula will develop acute or chronic diverticulitis that can lead to several complications some of which can be life-threatening.

CONCLUSION

AD is a rare surgical emergency and represents often an overlooked diagnosis. Early diagnosis and treatment are crucial for reducing morbidity and mortality Appendectomy represents a safe and appropriate treatment of AD.

Hidden appendix: A case report and literature review of perforated acute appendicitis masquerading as acute cholecystitis

Introduction

Acute appendicitis of the subhepatic appendix is uncommon, and a preoperative diagnosis is difficult without a thorough understanding of the various anatomical locations. Cross-sectional imaging is indispensable for prompt diagnosis and subsequent treatment. Surgery is the standard treatment for perforated appendicitis in the subhepatic region. In this study, we present a case of subhepatic appendicitis with an unusual presentation.

Case presentation

A 28-year-old man presented to our emergency department with a 3-day history of diffuse right abdominal discomfort, diarrhea, fever, and vomiting. Physical examination revealed rebound soreness and guarding in the right upper and lower quadrants. Laboratory tests revealed high levels of C-reactive protein and serum bilirubin and neutrophilic leukocytosis. Abdominal computed tomography revealed an undescended cecum and a subhepatic appendix with an intraluminal appendicolith, fat stranding, and peri-appendiceal fluid. The patient underwent open exploration and appendicectomy, during which the subhepatic perforated appendix was excised. The patient's recovery was uneventful.

Discussion

Atypical presentations may indicate an unusual anatomical placement of the appendix. Preoperative diagnosis using cross-sectional computed tomography imaging and a thorough understanding of these situations frequently result in early diagnosis and expeditious surgical care.

Conclusion

Surgical crises resulting from aberrant anatomical variations of the appendix constitute a distinct diagnostic challenge. A strong index of suspicion for this uncommon presentation permits early surgical intervention and prevents delay-induced morbidity/mortality.

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Appendicitis classically presents with right iliac fossa pain.

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Anomalous positions of the appendix can give rise to clinical challenges.

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Perforation in subhepatic appendicitis masquerades as acute cholecystitis.

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Undescended cecum could give rise to the rare anatomical position of the appendix.