Laparoscopy in Situs Inversus Totalis – a technical challenge
Author's: Boligo, Sofia1; Cardoso, Vasco Silva1; Monteiro, Ana Maria1; Maia Santos, Cristina1; Guerreiro, José1; Campos Costa, Filipa 2
Affiliations: 1 - General Surgery Department - Unidade Local de Saúde Lisboa Ocidental (ULSLO); 2 - General Surgery Department of Hospital Lusíadas Lisboa
ABSTRACT
Situs Inversus (SI) is a mirror transposition of the abdominal internal viscera, which may represent a diagnostic and surgical challenge.
Acute appendicitis is a frequent pathology in emergency department (ER) and the standard therapeutic approach is the same as in the patient without SI – laparoscopic appendectomy. However, it represents a technical challenge because there isn’t a standardized procedure technique in SI.
We present a case of acute appendicitis, in a male with SI totalis (SIt), in which a laparoscopic appendectomy was performed, describing the procedure step by step.
SI is an uncommon situation and laparoscopy has an important role as an initial surgical approach in patients with abdominal pain, even when conversion to open surgery is expected. Even though the inverted arrangement of intra-abdominal structures poses an orientation challenge, we consider the mirror approach technically feasible, reproducible, and safe when performed by an experienced surgeon in laparoscopy.
Keyword's: Situs Inversus, acute appendicitis, laparoscopy, appendectomy
INTRODUCTION
Situs Inversus (SI) is a mirror transposition of the abdominal internal viscera. It results from an autosomal recessive genetic defect. Has an incidence in the population of 0,001% - 0,01%, and a male:female ratio of 3:2. When associated with dextrocardia, it represents SI totalis (SIt).
Despite not affecting longevity of the patients, it may represent a diagnostic and surgical challenge, related to the atypical clinical presentation of certain diseases and making minimally invasive surgery technically more difficult.
On the other hand, laparoscopy surgery represents a valuable diagnostic and treatment tool in SI, because it allows a better understanding of the abdominal anatomy.
Acute appendicitis is a frequent pathology in emergency department (ER), which can be diagnosed by a detailed clinical history, physical examination, and proper radiological investigation. The therapeutic approach is the same as in the patient without SI – laparoscopic appendectomy (LA) [1,2]. The first LA in a SIt was described in 1998 by Contini et al. [3].
Laparoscopy is the recommended treatment, but also a diagnostic tool: only 50% have pain on the right side; inappropriate incisions can be prevented; and, the diagnostic and therapeutic delay is reduced, minimizing complications.
However, it represents a technical challenge because the procedure technique in SI has not been standardized yet.
To prevent future problems in diagnosis and treatment of appendicitis, some authors suggest that appendectomy should be done even prophylactically, if laparoscopy is done for another cause [4,5].
The objective of this paper is to present a case of acute appendicitis in a patient with SIt, its diagnostic approach and the technical features used in the surgical treatment.
CASE PRESENTATION
We present the case of a 21 years old healthy male, who presented to the ER with a 24-hour history of acute onset of left lower quadrant abdominal pain, without other associated symptoms. At physical examination was notable pain localized to left iliac fossa (LIF), without tenderness. The laboratory tests revealed leucocytosis with neutrophylia (26,1 x 109/L white cell count, 85,7% neutrophils) with a negative C-reactive protein (0,18 mg/dL). An abdominal ultrasonography was performed, which showed: “Situs inversus totalis (...) In LIF we identified distended, non-compressible appendix, with surrounding fat densification and small amount of adjacent free fluid, aspects that we associate with acute appendicitis.”
The patient was proposed for surgery, and a laparoscopic appendectomy was performed. The postoperative course and recovery were uneventful, and pathological examination of the excised appendix confirmed the diagnosis.
Laparoscopic Appendectomy in SI
Fig. 1. Intraoperative surgical team photograph.
Now, we present a detailed description of the procedure, that can be used as a standardized approach for LA in SI:
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The patient was in supine position under general anaesthesia;
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The monitors setted up at the level of patient’s left hip (figure 1 and 2);
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The surgeon was placed on the right side of the patient and the camera assistant at the level of patients’s right shoulder;
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A peri-umbilical incision was made;
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A Veress needle was used to create pneumoperitoneum, till 12 mmHg intraperitoneal pressure;
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A 10 mm trocar was placed at the umbilicus, for the 30º telescope;
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Confirmation of SI;
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Under direct vision, the remaining trocars were placed (figure 3);
- Right iliac fossa, 10 mm;
- Suprapubic region, 5 mm;
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The appendix was inflamed, 6,5 cm in length, at the base of the cecum;
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The appendicular artery was isolated from the mesoappendix and ligated using hem-o-loks ® (figure 4);
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The base of the appendix was ligated with hem-o-loks ®;
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Appendectomy was performed;
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The appendix was removed using an endobag®, through the umbilical port;
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Hemostasis was reviewed and peritoneal toilette was made;
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The aponeurosis, from the 10 mm ports, was closed using non-absorbable suture;
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The skin was closed using staples.
Fig. 2. Illustration showing the position of the patient and surgical team.
Fig. 3. Illustration of trocar placement for LA in SI.
Fig. 4. Mesoappendix being cauterized (photograph).
CONCLUSION
SI is an uncommon situation: there are no technical recommendations for minimally invasive approach in these patients (until 2018, there were only 4 published cases of LA in SI [6]).
Laparoscopy is recommended as an initial surgical approach in these patients with abdominal pain, even when conversion to open surgery is expected.
There are no standard locations for trocars:
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Publications suggest performing the procedure with the basic principles of laparoscopy - triangulation and ergonomy [6, 7];
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Palanivelu C. et al, for example, described a procedure using a 10 mm suprapubic (optical camera), 5 mm umbilicus (left hand) and 5 mm right iliac fossa (right hand) ports [8].
Even though the inverted arrangement of intra-abdominal structures poses an orientation challenge, we consider the mirror approach technically feasible, reproducible, and safe when performed by an experienced surgeon in minimal invasive surgery.
REFERENCES
[1] Patel et al., Laparoscopic Appendicectomy in a Patient with Situs Inversus Totalis, Indian J Surg (June 2013) 75 (Suppl1): S41–S43.
[2] Cissé et al., Appendicular peritonitis in situs inversus totalis: a case report Journal of Medical Case Reports 2010, 4:134.
[3] Contini S, Dalla Valle R, Zinicola R. Suspected appendicitis in situs inversus totalis: an indication for a laparoscopic approach. Surg Laparosc Endosc. 1998;8(5 ):393–394 [4] Keli E. et al., Laparoscopic appendicectomy in a patient with Situs Inversus Totalis, S Afr J Surg 2019;57 (2).
[5] Golash V. et al., Laparoscopic management of acute appendicitis in situs inversus. J Minim Access Surg 2006; 2: 220-1.
[6] Kong et al., Left-Sided Acute Appendicitis: a Case Report and a Review of Literature, Indian Journal of Surgery 2018.
[7] Song J, Rana S, Rotman, C. Laparoscopic Appendectomy in a Female Patient With Situs Inversus: Case Report and Literature Review. JSLS. 2004 Apr-Jun; 8(2): 175– 177.
[8] Palanivelu et al. (2007) Laparoscopic appendectomy for appendicitis in uncommon situations: the advantages of a tailored approach. Singapore Med J 48 (8):737–7.
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