|Year : 2014 | Volume
| Issue : 6 | Page : 760-763
Laparoscopic management of left-sided appendicitis in situs inversus totalis
Sangram Jadhav, Deepak Kulkarni, Siddarth P Dubhashi, Rajat D Sindwani
Department of Surgery, Dr. D. Y. Patil Medical College, Hosptial and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||18-Nov-2014|
Department of Surgery, Dr. D. Y. Patil Medical College, Hosptial and Research Centre, Dr. D. Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Situs inversus totalis is a rare autosomal recessive inherent disease in which the thoracic and abdominal organs are transposed. Incidence in the general population is only 0.001-0.01%. Symptoms of appendicitis may appear in the left lower quadrant making the diagnosis difficult. We report a case of left-sided appendicitis diagnosed preoperatively after dextrocardia that was detected by X-ray chest and ultrasonography revealed long retrocecal appendix in left iliac fossa with loops of bowel clumped in the area. The patient underwent laparoscopic appendectomy and post-operative recovery was uneventful. Although, technically more challenging because of the mirror nature of the anatomy, we used the conventional 3-port techniques after laparoscopic confirmation of anatomy and not the mirror image technique as is normally practiced. This method also provided the same comfort level to the surgeon.
Keywords: Appendicitis, laparoscopic appendectomy, situs inversus
|How to cite this article:|
Jadhav S, Kulkarni D, Dubhashi SP, Sindwani RD. Laparoscopic management of left-sided appendicitis in situs inversus totalis. Med J DY Patil Univ 2014;7:760-3
|How to cite this URL:|
Jadhav S, Kulkarni D, Dubhashi SP, Sindwani RD. Laparoscopic management of left-sided appendicitis in situs inversus totalis. Med J DY Patil Univ [serial online] 2014 [cited 2020 Sep 18];7:760-3. Available from: http://www.mjdrdypu.org/text.asp?2014/7/6/760/144869
| Introduction|| |
Even today, appendicitis is one of the most common surgical conditions, requiring elective and/or emergency surgery, accounting for 4-8% of all surgeries.  Situs inversus totalis (SIT) is a rare congenital disease which may go unrecognized until incidentally detected during imaging for unrelated conditions. Laparoscopy is indicated in these patients, as the clinical and imaging findings may be confusing in conjunction with acquired diseases. In patients with SIT, left lower quadrant pain can be a symptom of appendicitis and misdiagnosis or perforation of the appendix may occur. We report an unusual case of left-sided appendicitis with SIT.
| Case Report|| |
The case report is about a 43-year-old male patient who presented to the surgical out-patient department with chronic pain in the left side of the abdomen over a month. The patient also complained of nausea, without vomiting or diarrhea. He was afebrile. Patient gave a history of acute pain in the left lower side of abdomen 2 years ago for which he was treated conservatively. Since, then the pain has been mild dull aching oft and on until it got aggravated 1 month ago. Physical examination revealed a soft and flat abdomen with left-lower quadrant tenderness without rebound tenderness. A Clinical diagnosis of diverticular disease was made. His vital signs were normal with a total leucocyte count of 7,800/cu.mm. Renal profile, blood sugar and urine analysis were within the normal limits. Plain X-ray chest revealed dextrocardia [Figure 1]. Ultrasound examination showed situs inversus (SI) with liver and gall bladder on the left side, spleen on the right side and long retrocecal curved appendix with clumped loops of small bowel on the left side. This changed our diagnosis to SI and the left sided pathology was now thought to be appendicular in origin. Electrocardiogram findings were suggestive of dextrocardia and sinus rhythm. A laparoscopic appendectomy was planned after anesthesia fitness. A 10 mm umbilical port was inserted by the open method with telescope. At laparoscopy, the SI findings were confirmed. The cecum, ascending colon and retrocecal long curved appendix covered with omentum and omental adhesions to left lateral flank were identified. Second 10 mm trocar converted to camera port was inserted in suprapubic region. Third 5 mm working port was taken in the right iliac fossa near McBurney point for triangulation [Figure 2]. The operating surgeon and camera assistant were on the right side of the patient with the video cart on the left side of the patient near the lower half. The omentum was separated; thick and bulky mesoappendix was dissected from the long curved retrocecal appendix [Figure 3]. The base of appendix was ligated intracorporeally with 1/0 chromic catgut using Roeder's knot technique and delivered through the right iliac port. Operative time was 20 min. The specimen was sent for histopathology, which confirmed the presence of appendicitis. The patient was discharged on 3 rd post-operative day without any complications [Figure 4].
| Discussion|| |
SI is a congenital positional anomaly in which the abdominal viscera develop in the wrong position. The condition is known as SIT when both the thoracic and abdominal organs are transposed. SI is an autosomal recessive congenital defect with incidence of 0.001-0.01% in the general population. ,
The overlapping features of some situs anomalies and the presence of acute acquired diseases may result in confusing imaging findings with delayed diagnosis as a result of lack of uniformity in physical signs.  In the general population, left lower quadrant pain can be caused by many gastrointestinal diseases such as acute sigmoid diverticulitis, intestinal obstruction or perforation, incarcerated hernia, enteritis, atypical right sided and left sided appendicitis; genitourinary causes such as renal colic, cystitis, epididymitis, prostatitis, testicular torsion cyst, left ovarian disease, pelvic inflammatory disease and mesenteric ischemia. ,, Primarily, there are two different anatomic anomalies attributed to a left-sided appendix: SI and malrotation of the midgut loop. In normal development, the midgut rotates in a 270° counterclockwise direction and the position of the appendix lies in the right lower quadrant of the abdomen. SI develops when the rotation is made in a 270° clockwise direction and results in a complete reversal of all abdominal viscera and a left-sided appendix. Malrotation develops when there is non-rotation or incomplete rotation of the midgut loop around the axis of the superior mesenteric artery.  Concerning the pain location of left-sided appendicitis, Akbulut et al.  in their study have reported that 62% of the patients presented with left lower quadrant pain, 14% with right lower quadrant pain and 7% with bilateral pain. Since, the nervous system may not show corresponding transposition, pain location may be confusing and preoperative diagnosis has been made in only 51% of the patients. 
The diagnosis of SIT can be based on chest X-ray, ultrasound and computed tomography (CT) images. , Plain films are not helpful in the diagnosis of appendicitis but important in the diagnosis of SIT. Sonography is a widely used modality in the diagnosis but is operator-dependent and has difficulty in patients with a large body habitus or with overlying bowel gas.  In our case, chest X-ray revealed the existence of dextrocardia, which suggested SIT; confirmed by ultrasound and left lower quadrant pain. Laparoscopic appendectomy was then performed.
Laparoscopic appendectomy in SIT was reported first by Contini et al.  in 1997, but the technical procedure was not described. In regard to port site, Palanivelu et al.  used a 10 mm suprapubic port as right working port and a 5 mm umbilical port as camera port in left-sided appendicitis, but there were no standard port positions and they adopted a tailored approach to modify the port placements according to the basic principles of laparoscopy triangulation and ergonomy. Golash  used a 10 mm port in the left iliac fossa as a working port and a 5 mm port in suprapubic region.
We used 10 mm umbilical left hand working port; 5 mm right iliac as right working port; and 10 mm suprapubic as camera port with reasonable comfort. These trocar placements were similar to conventional port placements for right sided appendectomy with the difference in video cart placement. The operative time was also competitive with the right-sided method. Oms and Badia  have reported that handedness could influence the performance of operation in SI and we speculate that the same method could overcome this handicap more conveniently. We used the conventional intracorporeal Roeder's knot with 1/0 chromic catgut to tie the base of the appendix and laparoscopic scissors to cut the appendix. Laparoscopy is considerably beneficial both in terms of the differential diagnosis and as a definitive surgery in appendicitis in SI patients because the diagnosis is difficult and location of the appendix varies. ,
With the advent of single incision laparoscopic surgery (SILS) appendectomy, same umbilical incision with conventional ports and instrument or SILS port can accomplish the same purpose even in SI except that surgeon has to stand on the left side. In fact, it has been documented to be safe and feasible with superior cosmetic outcome. , SILS appendectomy had comparable operative times, length of hospital stay, complication rate, post-operative pain, better cosmesis and quality-of-life as with conventional three port laparoscopic appendectomy 
Patients with left lower quadrant pain, showing dextrocardia on chest X-ray are likely to have left-sided appendicitis. A strong suspicion of appendicitis, diagnosis by imaging modalities such as sonography or CT and laparoscopy can reduce the likelihood of misdiagnosis, perforation and abscess. Laparoscopic appendectomy in SI though technically more challenging due to mirror image of anatomy; can be safely and comfortably performed by the conventional port technique.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]