MJDRDYPU_20_14R2

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Case Report

Laparoscopic management of left-sided

appendicitis in situs inversus totalis
Sangram 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

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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

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.[1] 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

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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

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

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Jadhav, et al.: ???

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
Roeders 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 3rd postoperative day without any complications.

recessive congenital defect with incidence of 0.001-0.01%

in the general population.[2,3]

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

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.[4] 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.[1,4,5] 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

Figure 1: X-ray chest posterior-anterior view showing dextrocardia

Figure 2: Conventional port sites

Figure 3: Long inflamed appendix

Figure 4: Post-operative

Discussion

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AQ1

Jadhav, et al.: ???

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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.[4] Concerning the pain
location of left-sided appendicitis, Akbulut et al.[6] 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.[6]
The diagnosis of SIT can be based on chest X-ray, ultrasound
and computed tomography (CT) images.[5,6] Plain films are
not helpful in the diagnosis of appendicitis but important in
the diagnosis of SIT. Sonography is a widely used modality
inthe diagnosis but is operator-dependent and has difficulty
in patients with a large body habitus or with overlying bowel
gas.[6] 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.[7] in 1997, but the technical procedure was
not described. In regard to port site, Palanivelu et al.[8]
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[9] 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[10] 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 Roeders 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.[8,9]
Medical Journal of Dr. D.Y. Patil University | ?????-????? ???? | Vol ? | Issue ?

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.[11,12]
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[13]
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.

References
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cause. J Emerg Med 2001;20:241-5.
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intestinal obstruction with isolated levocardia. J Pediatr Surg
2000;35:1115-6.
3. Akbulut S, Caliskan A, Ekin A, Yagmur Y. Left-sided acute
appendicitis with situs inversus totalis: Review of 63 published
cases and report of two cases. J Gastrointest Surg 2010;14:1422-8.
4. Fulcher AS, Turner MA. Abdominal manifestations of situs
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12. Pelosi MA, Pelosi MA 3rd. Laparoscopic appendectomy using
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Jadhav, et al.: ???

13. Buckley FP3rd,Vassaur H, Monsivais S, Sharp NE, Jupiter D,Watson R,

et al. Comparison of outcomes for single-incision laparoscopic
inguinal herniorrhaphy and traditional three-port laparoscopic
herniorrhaphy at a single institution. Surg Endosc 2014;28:30-5.

How to cite this article: Citation will be included before issue gets
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Source of Support: Nil. Conflict of Interest: None declared.

Author Queries???
AQ1: Kindly provide running title.
AQ2: Please cite Figure 4 inside the text part.

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

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