Surgical management of subhepatic perforated appendicitis: a
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A 41-year-old woman, with a history of two normal vaginal deliveries followed by a cesarean section 1-year earlier, in August 2019. She presented to the hospital with abdominal pain of 3-days’ duration. The pain had started in the epigastric region, progressed in intensity over the 3-days, and became prominent in the right upper and lower quadrants. It was associated with one episode of nonbilious emesis and by mouth intolerance at home.

Upon presentation in the emergency department (ED), the patient was hypotensive with a blood pressure of 90/40 mmHg, tachycardic with a heart rate of 112 beats/minute, and febrile to 38.2 °C, and she also showed signs of dehydration. She was conscious, alert, and oriented with a Glasgow Coma Scale score of 15, with unlabored breathing and normal vesicular breath sounds. Her abdominal examination showed a soft abdomen with tenderness to palpation in all the quadrants, prominently in the right upper and lower quadrants, and signs of peritonitis such as rebound tenderness and severe pain on percussion were present in the right abdomen. The patient was given a 1-L bolus of Ringer’s lactate in the ED with a response of 100 mmHg systolic blood pressure. An ultrasound of the patient’s abdomen showed subhepatic intraperitoneal fluid collection and inability to visualize the appendix. Axial computed tomography (CT) with by mouth and intravenous contrast showed subhepatic perforated appendicitis with subhepatic and pelvic collections. The patient was started on intravenous ceftriaxone 1 g twice daily, intravenous metronidazole 500 mg thrice daily, and intravenous paracetamol 1 g thrice daily in the ED until discharge.

Under aseptic precautions and general anesthesia, the patient was placed in a supine position. A midline laparotomy incision was made. Upon entering the peritoneal cavity, a short ascending colon with a subhepatic perforated appendix acutely inflamed with a subhepatic collection was noticed. Localized peritonitis was present. A pyogenic membrane was noticed under the liver and between the liver and the diaphragm. A purulent collection was also noticed in the pouch of Douglas. An appendicectomy was performed. Complete hemostasis was achieved. Adequate peritoneal lavage was done with normal saline. After drainage of almost all the fluid, a right subhepatic drain and a left pelvic drain was placed. Abdominal wall closure of the rectus with a polydioxanone suture and skin staples was done. The patient was extubated in stable condition. No complications occurred. The patient did well on a postoperative day 1 (POD1) and tolerated her diet, and the drains were subsequently removed on POD2. The patient was discharged home in a good condition and expressed gratitude. Postoperative follow-up at 2 weeks and at 6 months showed good healing and recovery of the patient.