8/18/2019 Lap Appendectomy in Situs Inversus

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Medical Journal of Dr. D.Y. Patil University | ?????-????? ???? | Vol ? | Issue ?

Address for correspondence:Dr. Sangram Jadhav, Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hosptial and Research Centre, Dr. D. Y. Patil Vidyapeeth,Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra, India. E-mail: sangramjadhav@hotmail.com

IntroductionEven today, appendicitis is one of the most common surgicalconditions, requiring elective and/or emergency surgery,accounting for 4-8% of all surgeries. [1] Situs inversus totalis(SIT) is a rare congenital disease which may go unrecognizeduntil incidentally detected during imaging for unrelatedconditions. Laparoscopy is indicated in these patients,as the clinical and imaging ndings may be confusing inconjunction with acquired diseases. In patients with SIT, leftlower quadrant pain can be a symptom of appendicitis andmisdiagnosis 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 whopresented to the surgical out-patient department with

Laparoscopic management of left-sidedappendicitis in situs inversus totalisSangram Jadhav, Deepak Kulkarni, Siddarth P. Dubhashi, Rajat D. Sindwani

Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hosptial and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India

ABSTRACT

Situs inversus totalis is a rare autosomal recessive inherent diseasein which the thoracic and abdominal organs are transposed.Incidence in the general population is only 0.001-0.01%. Symptomsof appendicitis may appear in the left lower quadrant making thediagnosis dif cult. We report a case of left-sided appendicitisdiagnosed preoperatively after dextrocardia that was detected byX-ray chest and ultrasonography revealed long retrocecal appendixin left iliac fossa with loops of bowel clumped in the area. The patientunderwent laparoscopic appendectomy and post-operative recoverywas uneventful. Although, technically more challenging because ofthe mirror nature of the anatomy, we used the conventional 3-porttechniques after laparoscopic con rmation of anatomy and not themirror image technique as is normally practiced. This method also

provided the same comfort level to the surgeon.

Keywords: Appendicitis, laparoscopic appendectomy, situs inversus

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Case Report

chronic pain in the left side of the abdomen over a month.The patient also complained of nausea, without vomitingor diarrhea. He was afebrile. Patient gave a history ofacute pain in the left lower side of abdomen 2 years ago forwhich he was treated conservatively. Since, then the painhas been mild dull aching oft and on until it got aggravated1 month ago. Physical examination revealed a soft and atabdomen with left-lower quadrant tenderness withoutrebound tenderness. A Clinical diagnosis of diverticulardisease was made. His vital signs were normal with atotal leucocyte count of 7,800/cu.mm. Renal pro le,blood sugar and urine analysis were within the normallimits. Plain X-ray chest revealed dextrocardia [Figure 1] .Ultrasound examination showed situs inversus (SI) withliver and gall bladder on the left side, spleen on the rightside and long retrocecal curved appendix with clumpedloops of small bowel on the left side. This changed ourdiagnosis to SI and the left sided pathology was nowthought to be appendicular in origin. Electrocardiogramfindings were suggestive of dextrocardia and sinusrhythm. A laparoscopic appendectomy was planned after

anesthesia tness. A 10 mm umbilical port was insertedby the open method with telescope. At laparoscopy,the SI ndings were con rmed. The cecum, ascendingcolon and retrocecal long curved appendix covered withomentum and omental adhesions to left lateral ank wereidenti ed. Second 10 mm trocar converted to camera port

MJDRDYPU_20_14R2

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Jadhav, et al .: ???AQ1

2 Medical Journal of Dr. D.Y. Patil University | ?????-????? ???? | Vol ? | Iss

was inserted in suprapubic region. Third 5 mm workingport was taken in the right iliac fossa near McBurneypoint for triangulation [Figure 2]. The operating surgeonand camera assistant were on the right side of the patientwith the video cart on the left side of the patient nearthe lower half. The omentum was separated; thick andbulky mesoappendix was dissected from the long curvedretrocecal appendix [Figure 3]. The base of appendix wasligated intracorporeally with 1/0 chromic catgut usingRoeder’s knot technique and delivered through the rightiliac port. Operative time was 20 min. The specimen wassent for histopathology, which con rmed the presenceof appendicitis. The patient was discharged on 3 rd post-operative day without any complications.

Discussion

SI is a congenital positional anomaly in which the

abdominal viscera develop in the wrong position. Thecondition is known as SIT when both the thoracic andabdominal organs are transposed. SI is an autosomal

recessive congenital defect with incidence of 0.001-0.01%in the general population. [2,3]

The overlapping features of some situs anomalies andthe presence of acute acquired diseases may result inconfusing imaging findings with delayed diagnosis asa result of lack of uniformity in physical signs. [4] In thegeneral population, left lower quadrant pain can be causedby many gastrointestinal diseases such as acute sigmoiddiverticulitis, intestinal obstruction or perforation,incarcerated hernia, enteritis, atypical right sided andleft sided appendicitis; genitourinary causes such as renalcolic, cystitis, epididymitis, prostatitis, testicular torsioncyst, left ovarian disease, pelvic in ammatory disease andmesenteric ischemia. [1,4,5] Primarily, there are two differentanatomic anomalies attributed to a left-sided appendix: SIand 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 lowerquadrant of the abdomen. SI develops when the rotationis made in a 270° clockwise direction and results in a

Figure 4 : Post-operative AQ

Figure 1: X-ray chest posterior-anterior view showing dextrocardia Figure 2: Conventional port sites

Figure 3: Long infamed appendix

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Jadhav, et al .: ??? AQ

Medical Journal of Dr. D.Y. Patil University | ?????-????? ???? | Vol ? | Issue ?

complete reversal of all abdominal viscera and a left-sidedappendix. Malrotation develops when there is non-rotationor incomplete rotation of the midgut loop around the axisof the superior mesenteric artery. [4] Concerning the painlocation of left-sided appendicitis, Akbulut et al .[6] in theirstudy have reported that 62% of the patients presented withleft lower quadrant pain, 14% with right lower quadrantpain and 7% with bilateral pain. Since, the nervous systemmay not show corresponding transposition, pain locationmay be confusing and preoperative diagnosis has been madein only 51% of the patients. [6]

The diagnosis of SIT can be based on chest X-ray, ultrasoundand computed tomography (CT) images. [5,6] Plain lms arenot helpful in the diagnosis of appendicitis but important inthe diagnosis of SIT. Sonography is a widely used modalityin the diagnosis but is operator-dependent and has dif cultyin patients with a large body habitus or with overlying bowel

gas.[6]

In our case, chest X-ray revealed the existence ofdextrocardia, which suggested SIT; con rmed by ultrasoundand left lower quadrant pain. Laparoscopic appendectomywas then performed.

Laparoscopic appendectomy in SIT was reported rst byContini et al .[7] in 1997, but the technical procedure wasnot described. In regard to port site, Palanivelu et al .[8] used a 10 mm suprapubic port as right working portand a 5 mm umbilical port as camera port in left-sidedappendicitis, but there were no standard port positionsand they adopted a tailored approach to modify theport placements according to the basic principles oflaparoscopy triangulation and ergonomy. Golash [9] useda 10 mm port in the left il iac fossa as a working port anda 5 mm port in suprapubic region.

We used 10 mm umbilical left hand working port; 5 mmright iliac as right working port; and 10 mm suprapubicas camera port with reasonable comfort. These trocarplacements were similar to conventional port placements forright sided appendectomy with the difference in video cartplacement. The operative time was also competitive with

the right-sided method. Oms and Badia[10]

have reported thathandedness could in uence the performance of operation inSI and we speculate that the same method could overcomethis handicap more conveniently. We used the conventionalintracorporeal Roeder’s knot with 1/0 chromic catgut to tiethe base of the appendix and laparoscopic scissors to cut theappendix. Laparoscopy is considerably bene cial both interms of the differential diagnosis and as a de nitive surgeryin appendicitis in SI patients because the diagnosis is dif cultand location of the appendix varies. [8,9]

With the advent of single incision laparoscopic surgery(SILS) appendectomy, same umbilical incision withconventional ports and instrument or SILS port canaccomplish the same purpose even in SI except that surgeonhas to stand on the left side. In fact, it has been documentedto be safe and feasible with superior cosmetic outcome. [11,12] SILS appendectomy had comparable operative times, lengthof hospital stay, complication rate, post-operative pain,better cosmesis and quality-of-life as with conventionalthree port laparoscopic appendectomy [13]

Patients with left lower quadrant pain, showing dextrocardiaon chest X-ray are likely to have left-sided appendicitis.A strong suspicion of appendicitis, diagnosis by imagingmodalities such as sonography or CT and laparoscopycan reduce the likelihood of misdiagnosis, perforationand abscess. Laparoscopic appendectomy in SI thoughtechnically more challenging due to mirror image of

anatomy; can be safely and comfortably performed by theconventional port technique.

References1. Nelson MJ, Pesola GR. Left lower quadrant pain of unusual

cause. J Emerg Med 2001;20:241-5.2. Budhiraja S, Singh G, Miglani HP, Mitra SK. Neonatal

intestinal obstruction with isolated levocardia. J Pediatr Surg2000;35:1115-6.

3. Akbulut S, Caliskan A, Ekin A, Yagmur Y. Left-sided acuteappendicitis with situs inversus totalis: Review of 63 publishedcases and report of two cases. J Gastrointest Surg 2010;14:1422-8.

4. Fulcher AS, Turner MA. Abdominal manifestations of situs

anomalies in adults. Radiographics 2002;22:1439-56.5. Cartwright SL, Knudson MP. Evaluation of acute abdominal

pain in adults. Am Fam Physician 2008;77:971-8.6. Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y. Left-sided

appendicitis: Review of 95 published cases and a case report.World J Gastroenterol 2010;16:5598-602.

7. Contini S, Dalla Valle R, Zinicola R. Suspected appendicitisin situs inversus totalis: An indication for a laparoscopicapproach. Surg Laparosc Endosc 1998;8:393-4.

8. Palanivelu C, Rangarajan M, John SJ, Senthilkuma r R,Madhankumar MV. Laparoscopic appendectomy for appendicitisin uncommon situations: The advantages of a tailored approach.Singapore Med J 2007;48:737-40.

9. Golash V. Laparoscopic management of acute appendicitisin situs inversus. J Minim Access Surg 2006;2:220-1.

10. Oms LM, Badia JM. Laparoscopic cholecystectomy in situs inversus totalis: The importance of being left-handed. SurgEndosc 2003;17:1859-61.

11. Bhatia P, Sabharwal V, Kalhan S, John S, Deed JS, Khetan M.Single-incision multi-port laparoscopic appendectomy: How Ido it. J Minim Access Surg 2011;7:28-32.

12. Pelosi MA, Pelosi MA 3 rd. Laparoscopic appendectomy usinga single umbilical puncture (minilaparoscopy). J Reprod Med1992;37:588-94.

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13. Buckley FP 3 rd, Vassaur H, Monsivais S, Sharp NE, Jupiter D, Watson R,et al . Comparison of outcomes for single-incision laparoscopicinguinal herniorrhaphy and traditional three-port laparoscopicherniorrhaphy at a single institution. Surg Endosc 2014;28:30-5.

How to cite this article: Citation will be included before issue getsonline***

Source of Support: Nil. Con ict of Interest: None declared.

Author Queries???AQ1: Kindly provide running title.

AQ2: Please cite Figure 4 inside the text part.