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BMJ Case Rep. 2010; 2010: bcr0420102883.
Published online 2010 September 21. doi:  10.1136/bcr.04.2010.2883
PMCID: PMC3029877
Images in…

Incidental finding of an anterior sub-hepatic appendix during laparoscopic cholecystectomy

Description

Young women with no past surgical history presented with recurrent biliary colic. Abdominal ultrasound scan confirmed gallstones and she was listed for laparoscopic cholecystectomy. An incidental finding of an anterior sub-hepatic normal appendix was made during the operation. We are not aware of any previous normal sub-hepatic appendix images in the literature.

The presence of a sub-hepatic appendix is rare and usually retrocaecal. Palanivelu et al1 reported an incidence of 0.08% sub-hepatic appendix in 7210 appendicitis in India. Sub-hepatic appendicitis cases are usually missed preoperatively and only diagnosed at laparoscopy. Sub-hepatic appendicular abscess is the most reported presentation. Sub-hepatic appendicitis could easily mimic acute cholecystitis symptoms2 and the presence of fecalith could be mistaken for gallstones in an ultrasound scan examination.

Figure 1
Normal anterior sub-hepatic appendix incidentally found next to the gallbladder during laparoscopic cholecystectomy.

Learning points

  • Sub-hepatic appendix is a rare anatomic variation and it is usually in retrocaecal position.
  • Sub-hepatic appendicitis mimic acute cholecystitis symptoms and should be suspected in young patients.
  • Ultrasound scan examination could confuse sub-hepatic appendicitis with cholecystitis due to the anatomic position and the possible presence of fecalith.
  • Laparoscopic procedure is the treatment of choice for such cases.

Footnotes

Competing interests None.

Patient consent Obtained.

References

1. Palanivelu C, Rangarajan M, John SJ, et al. Laparoscopic appendectomy for appendicitis in uncommon situations: the advantages of a tailored approach. Singapore Med J 2007;48:737–40. [PubMed]
2. Patel NR, Lakshman S, Hays TV, et al. Subhepatic appendix with fecalith mimicking acute cholecystitis with gallstone. J Clin Ultrasound 1996;24:45–7. [PubMed]

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