J Korean Surg Soc.  2012 Sep;83(3):175-178. 10.4174/jkss.2012.83.3.175.

Left-sided appendicitis in a patient with situs inversus totalis

• Oh JS
• Kim KW
• Cho HJ

• KMID: 2212291
• DOI: http://doi.org/10.4174/jkss.2012.83.3.175

Abstract

Situs inversus totalis is a rare inherent disease in which the thoracic and abdominal organs are transposed. Symptoms of appendicitis in situs inversus (SI) may appear in the left lower quadrant, and the diagnosis of appendicitis is very difficult. We report a case of left-sided appendicitis diagnosed preoperatively after dextrocardia that was detected by chest X-ray, although the chief complaint of the patient was left lower-quadrant pain. The patient underwent an emergent laparoscopic appendectomy under the diagnosis of appendicitis after abdominal computed tomography (CT). In patients with left lower quadrant pain, if the chest X-ray shows dextrocardia, one should suspect left-sided appendicitis. A strong suspicion of appendicitis and an emergency laparoscopic operation after confirmation of the diagnosis by imaging modalities including abdominal CT or sonography can reduce the likelihood of misdiagnosis and complications including perforation and abscess. Laparoscopic appendectomy in SI was technically more challenging because of the mirror nature of the anatomy.

Keyword

Situs inversus; Appendicitis; Laparoscopic; Appendectomy

MeSH Terms

Abscess
Appendectomy
Appendicitis
Dextrocardia
Diagnostic Errors
Emergencies
Humans
Situs Inversus
Thorax

Figure

• 

  Fig. 1 A chest X-ray shows dextrocardia.

• 

  Fig. 2 Axial abdominal computed tomography shows an enlarged wall and an enhanced appendix (arrow).

• 

  Fig. 3 Coronal abdominal computed tomography demonstrates the existence of situs inversus totalis including dextrocardia and an inflamed appendix (arrow).

• 

  Fig. 4 Port sites for right-sided appendicitis (A) and left-sided appendicitis (B) show mirror image.

• 

  Fig. 5 Laparoscopy demonstrates the existence of a left-sided appendix with cecum.

Reference

1. Nelson MJ, Pesola GR. Left lower quadrant pain of unusual cause. J Emerg Med. 2001. 20:241–245.

2. Budhiraja S, Singh G, Miglani HP, Mitra SK. Neonatal intestinal obstruction with isolated levocardia. J Pediatr Surg. 2000. 35:1115–1116.

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. 14:1422–1428.

4. 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. 16:5598–5602.

5. Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008. 77:971–978.

6. Nelson MJ, Pesola GR. Left lower quadrant pain of unusual cause. J Emerg Med. 2001. 20:241–245.

7. Contini S, Dalla Valle R, Zinicola R. Suspected appendicitis in situs inversus totalis: an indication for a laparoscopic approach. Surg Laparosc Endosc. 1998. 8:393–394.

8. Palanivelu C, Rangarajan M, John SJ, Senthilkumar R, Madhankumar MV. Laparoscopic appendectomy for appendicitis in uncommon situations: the advantages of a tailored approach. Singapore Med J. 2007. 48:737–740.

9. Golash V. Laparoscopic management of acute appendicitis in situs inversus. J Minim Access Surg. 2006. 2:220–221.

10. Oms LM, Badia JM. Laparoscopic cholecystectomy in situs inversus totalis: the importance of being left-handed. Surg Endosc. 2003. 17:1859–1861.