Acute appendicitis in a patient with situs viscerum inversus totalis: Role of laparoscopic approach. A case report and brief literature review

Left-sided perforated appendicitis in a patient with situs inversus totalis, a case report

Situs inversus, an uncommon disorder, causes the orientation of asymmetric organs to be opposite to that of normal anatomy. It can be either partial, affecting only the thoracic or abdominal cavities, or full, involving the transposition of both the thoracic and abdominal organs. A 31-year-old Ethiopian male patient presented with migratory abdominal pain in the left lower quadrant for 3 days. Associated with the pain, he experienced symptoms of nausea, vomiting of ingested matter, and loss of appetite. Investigations were consistent with left-sided appendicitis with situs inversus totalis. Therefore, the patient was operated on and discharged with no perioperative complications. Appendicitis is a rare cause of left lower quadrant pain. In order to reduce the delay in patient treatment and avoidable perioperative complications, emergency physicians, radiologists, and surgeons must become more knowledgeable about situs inversus and left side appendicitis.

Left side perforated appendicitis with intestinal non-rotation: a case report

BACKGROUND

Acute appendicitis is the most common cause of acute abdominal pain, requiring emergency surgery. Symptoms and signs of acute appendicitis usually occur in the right lower quadrant. However, approximately one-third of cases have pain unexcepted location due to its various anatomical locations. Acute appendicitis is a very rare cause of left lower quadrant pain; if it occurs, situs inversus (SI) and midgut malrotation (MM) are uncommon anatomic anomalies that complicate its diagnosis and management.

CLINICAL PRESENTATION

Here we present a 23-year-old Ethiopian male patient who presented with epigastric and left paraumbilical abdominal pain, fever, and vomiting of a day duration. On examination at admission, the patient had left lower quadrant tenderness. Later, with the help of imaging studies, the patient was diagnosed with left-side acute perforated appendicitis with intestinal nonrotation, and he was operated on and discharged improved after 6 days of hospital stay.

CONCLUSION

Physicians should be aware that acute appendicitis in patients with intestinal mal-rotation may be present with left-side abdominal pain. Although it is extremely rare, acute appendicitis should always be considered in the differential diagnosis of left-side abdominal pain. An increase in awareness of this anatomical variant is essential for physicians.

Laparoscopic common bile duct exploration to treat choledocholithiasis in situs inversus patients: A technical review

Situs inversus (SI) is a rare congenital condition characterized by a mirror-image transposition of the major visceral organs. Since the 1990s, more than one hundred SI patients have been reported to have successfully undergone laparoscopic cholecystectomy. In these cases, the major problem is to overcome is the left-right condition for right-handed surgeons. Laparoscopic common bile duct exploration (LCBDE), an alternative to treat patients with bile duct stones, has shown equivalent efficacy and is less likely to cause pancreatitis than endoscopic retrograde cholangiopancreatography. Recent updated meta-analyses revealed that a shorter postoperative hospital stay, fewer procedural interventions, cost-effectiveness, a higher stone clearance rate, and fewer perioperative complications are additional advantages of LCBDE. However, the technique is technically demanding, even for skilled laparoscopic surgeons. Conducting LCBDE in patients with difficult situations, such as SI, is more complex than usual. We herein review published SI patients with choledocholithiasis treated by LCBDE, including our own experience, and this paper focuses on the technical aspects.

Laparoscopic appendectomy in an adult patient with situs inversus totalis

Left-sided appendicitis is usually caused by situs inversus totalis or midgut malrotation. Clinical and imaging diagnoses have been presented relatively fully in the literature. However, this is a rare condition, and each related case should be further reported to help the day-to-day clinician better investigate and understand. Therefore, in this paper, we present a case of left-sided acute appendicitis in an adult male patient with situs inversus totalis. In addition, we also discuss the laparoscopic technique of the left-sided appendectomy as it is technically more difficult because of the mirror nature of the anatomy.

Acute appendicitis and situs viscerum inversus: radiological and surgical approach-a systematic review

INTRODUCTION

Acute appendicitis is one of the most frequent intra-abdominal diseases requiring emergency surgical consult and treatment. The diagnosis of this condition is based on clinical features and radiologic findings. One-third of patients with acute appendicitis present unusual symptoms. There are several circumstances that may cause misdiagnosis and unclear prognostic prediction. Among these, situs viscerum inversus totalis and midgut malrotation can be challenging scenarios, leading to a delay in treatment, especially when these conditions are unknown. We decided to carry on a systematic review of published cases of acute appendicitis in the context of anatomical anomalies.

METHODS

We used the MESH terms "appendicitis" AND "situs inversus" AND/OR "gut malrotation" to search for titles and abstracts. Inclusion criteria were patients with clinical and/or radiological diagnosis of acute appendicitis, with conservative or surgical management and with preoperative/intraoperative findings of situs viscerum inversus or gut malrotation. Additionally, previous reviews were examined. Exclusion criteria of the studies were insufficient patient clinical and demographic data.

RESULTS

We included in this review 70 articles concerning 73 cases of acute appendicitis with anatomical anomaly. Patients were aged from 8 to 86 years (median: 27.0 years). 50 were male and 23 were female. 46 patients (63%) had situs viscerum inversus, 24 (33%) had midgut malrotation, 2 (2.7%) had Kartagener's syndrome, one of them (1.4%) had an undetermined anomaly In 61 patients the anatomical anomaly was unknown previously (83.6%), while 16,4% already were aware of their condition.

CONCLUSION

Acute appendicitis can occur in association of rare anatomical anomalies and in these cases diagnosis can be challenging. Situs viscerum inversus and midgut malrotation should always be considered in the differential diagnosis of a patient with left lower quadrant pain, especially in younger population. Besides clinical features, it is fundamental to implement the diagnostic progress with radiological examination. Laparoscopic approach is useful to identify and treat acute surgical emergency and it is also a diagnostic tool and can be tailored in order to offer the best exposition of the operatory field for each single case.

Hidden appendix: A case report and literature review of perforated acute appendicitis masquerading as acute cholecystitis

Introduction

Acute appendicitis of the subhepatic appendix is uncommon, and a preoperative diagnosis is difficult without a thorough understanding of the various anatomical locations. Cross-sectional imaging is indispensable for prompt diagnosis and subsequent treatment. Surgery is the standard treatment for perforated appendicitis in the subhepatic region. In this study, we present a case of subhepatic appendicitis with an unusual presentation.

Case presentation

A 28-year-old man presented to our emergency department with a 3-day history of diffuse right abdominal discomfort, diarrhea, fever, and vomiting. Physical examination revealed rebound soreness and guarding in the right upper and lower quadrants. Laboratory tests revealed high levels of C-reactive protein and serum bilirubin and neutrophilic leukocytosis. Abdominal computed tomography revealed an undescended cecum and a subhepatic appendix with an intraluminal appendicolith, fat stranding, and peri-appendiceal fluid. The patient underwent open exploration and appendicectomy, during which the subhepatic perforated appendix was excised. The patient's recovery was uneventful.

Discussion

Atypical presentations may indicate an unusual anatomical placement of the appendix. Preoperative diagnosis using cross-sectional computed tomography imaging and a thorough understanding of these situations frequently result in early diagnosis and expeditious surgical care.

Conclusion

Surgical crises resulting from aberrant anatomical variations of the appendix constitute a distinct diagnostic challenge. A strong index of suspicion for this uncommon presentation permits early surgical intervention and prevents delay-induced morbidity/mortality.

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Appendicitis classically presents with right iliac fossa pain.

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Anomalous positions of the appendix can give rise to clinical challenges.

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Perforation in subhepatic appendicitis masquerades as acute cholecystitis.

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Undescended cecum could give rise to the rare anatomical position of the appendix.

A Case Report of Laparoscopic Left-Sided Appendectomy in a Child With Situs Inversus

Acute appendicitis classically elicits right-sided abdominal pain. Abdominal pain in patients with situs inversus may create a diagnostic challenge. We share a case of a seven-year-old boy who presented to the emergency department with left lower quadrant abdominal pain and tenderness. A chest x-ray showed dextrocardia and an abdominal ultrasound confirmed left-sided appendicitis. Diagnostic laparoscopy and appendectomy were uneventful. Thorough peri-operative evaluation and planning are key to a successful outcome in this rare condition.

WAYS TO IMPROVE THE RESULTS OF SURGICAL TREATMENT OF PATIENTS WITH ATYPICAL FORMS OF ACUTE APPENDICITIS

OBJECTIVE

The aim: To search for new and improvement of known methods of diagnosis and surgical treatment of atypical forms of acute appendicitis.

PATIENTS AND METHODS

Materials and methods: There were analyzed the results of diagnosis and surgical treatment of 852 patients with atypical course of acute appendicitis, which amounted to 25.3% of the total number of patients in this category. Depending on the chosen diagnostic and treatment tactics, patients with acute atypical appendicitis were divided into two groups: control (n=423) and main (n=429).

RESULTS

Results: It was found that among atypical forms of acute appendicitis retrocecal location of the appendix is 61.2% of cases, pelvic - 24.3%, medial - 11.2%, subhepatic - 3.4%. Destructive forms of atypical acute appendicitis occurred in a total of 92.5% of cases, 77.7% of patients had various types of peritonitis.

CONCLUSION

Conclusions: Authors improved and tested a number of diagnostic (rectal thermometry, ethanol test) and operative methods for destructive forms of acute appendicitis complicated by typhoid (including laparoscopic). The proposed diagnostic and treatment algorithm allowed to optimize the treatment tactics of this category of patients and reduce the incidence of complications in the early postoperative period from 9.9% to 3.5% (p<0.001).

Acute Appendicitis Presenting As Epigastric Pain Due to Incomplete Intestinal Malrotation

Acute appendicitis is one of the most frequent causes of acute abdominal pain. Clinical signs, blood tests, and imaging are important to confirm the diagnosis. The classic presentation consists of periumbilical abdominal pain that migrates to the right lower quadrant, guarding, tenderness, and rebound tenderness in the region. We present the case of a 51-year-old male who presented with a one-day history of worsening supraumbilical pain. Abdominal computerized tomography (CT) scan showed intestinal malrotation in which the cecum assumed a midline supraumbilical location with CT features of acute appendicitis. This case highlights that the site of pain in acute appendicitis can be altered depending upon the anatomical location of the appendix, and relying on the pain’s location can be misleading. We also suggest that patients with abdominal pain, which is not typical for acute appendicitis, should be investigated by abdominal CT if leukocytosis and inflammatory markers are raised.