Page 31 - World Journal of Laparoscopic Surgery

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10.5005/jp-journals-10033-1308
Management of Acute Appendicitis and Left Paraovarian Cyst in a Case of Situs Inversus Totalis by Laparoscopy
CASE REPORT

Management of Acute Appendicitis and Left Paraovarian

Cyst in a Case of Situs Inversus Totalis by Laparoscopy

2
1 Samir S Deolekar, Dnyaneshwar Mohare, Anuj Sharma
3
ABSTRACT abdominal organs are transposed. The incidence of SIT
Introduction: Situs inversus totalis (SIT) is an entity in which is approximately 1/1,400 to 1/35,000 in the general popu-
there is transposition of both the abdominal and thoracic lation. Acute abdomen in SIT possesses a big diagnostic
organs. Presentation of acute abdomen in a case of SIT poses dilemma as though the viscus is transposed, but their
a challenge to the treating surgeon. We present a rare case nervous innervation may follow the normal original
report in which we identify the role of laparoscopy in confirming
acute appendicitis with a simultaneous left paraovarian hemor- distribution as in 50% of the individuals. The incidence
rhagic cyst as a cause of left iliac fossa pain. of acute appendicitis associated with SIT is reported to
2,3
be between 0.016 and 0.024%. Laparoscopy is a valuable
Case report: A 17-year-old female presented with pain in the
left lower abdominal quadrant. Ultrasonography and computed tool in surgeon’s hand in case of SIT with acute abdomen,
tomography confirmed a left-sided inflamed appendix and a which provides confirmatory and definitive surgery of
left paraovarian hemorrhagic cyst along with transposition of involved pathology. 4
other organs. A diagnostic laparoscopy was done to confirm the To the best of our knowledge, there are no reported
diagnosis with subsequent appendectomy and cyst enucleation
as a definitive treatment for left iliac fossa pain. cases of acute abdomen due to acute appendicitis associ-
ated with left paraovarian hemorrhagic cyst in patients
Discussion: Management of acute abdomen in a case of SIT
can be challenging, keeping in mind the transposed organs and with SIT.
also that the nervous supply may still be normal in up to 50%
of the cases. The role of diagnostic laparoscopy is pertinent in CASE REPORT
arriving at diagnosing and treatment of the underlying pathology
or pathologies as in our case. A 17-year-old female presented in the casualty ward
with complaints of left lower quadrant nonradiating
Keywords: Abdominal pain, Appendicitis, Paraovarian cyst,
Situs inversus totalis. pain for 1 day. The patient had history of nausea, but
no fever, vomiting, or diarrhea. There was no history of
How to cite this article: Deolekar SS, Mohare D, Sharma A.
Management of Acute Appendicitis and Left Paraovarian Cyst associated abdominal or any previous similar attack of
in a Case of Situs Inversus Totalis by Laparoscopy. World pain in abdomen. The patient had a normal menstrual
J Lap Surg 2017;10(2):73-76. history with no comorbid conditions like tuberculosis,
Source of support: Nil diabetes, etc. She was hemodynamically stable and on
physical examination revealed tenderness in the left
Conflict of interest: None
iliac fossa with localized guarding. Laboratory investi-
gations revealed a raised total leukocyte count of 13,500
INTRODUCTION cells/mL, with a differential neutrophil count of 85% of
Situs inversus (SI) is a rare congenital developmental the total cells. The liver function tests and renal func-
anomaly occurring with an incidence of 1:5,000 to tion tests were within the normal limits. A plain chest
1:10,000 live births in which abdominal organs are radiograph showed the presence of dextrocardia with a
1
placed as mirror image of each other. There is no racial gastric bubble on the right side. Ultrasonography (USG)
predilection, and sex incidence is 1:1. Situs inversus revealed a tubular, aperistaltic structure in the left iliac
totalis (SIT) is a condition in which both thoracic and fossa with a diameter of 9 mm along with a paraovarian
cyst of size 8 × 12 mm and transposition of the abdomi-
nal organs. The abdominal computed tomography (CT)
1 Associate Professor, Assistant Professor, Registrar revealed the presence of a contrast-enhanced appendix
2
3
with the maximum diameter of 9.5 mm and adjacent fat
1-3 Department of General Surgery, King Edward Memorial
Hospital and Seth Gordhandas Sunderdas Medical College stranding along with a left paraovarian cyst of diameter
Mumbai, Maharashtra, India 9 × 12 mm (Fig. 1) in size with transposed intraabdominal
Corresponding Author: Anuj Sharma, Registrar, Department organs (Fig. 2). A diagnostic laparoscopy was planned in
of General Surgery, King Edward Memorial Hospital and Seth view of localized guarding and raised white blood cell
Gordhandas Sunderdas Medical College, Mumbai, Maharashtra count. A 10 mm umbilical port was placed with open
India, Phone: +917303907379, e-mail: anuj9863@gmail.com
technique. The second 10 mm working port was placed
World Journal of Laparoscopic Surgery, May-August 2017;10(2):73-76 73