Intraoperative diagnosis of left-sided appendicitis in a patient with partial situs inversus and levocardia: a rare case report

Abstract

Acute appendicitis is common surgical conditions, requiring an emergency operation and accounting for 4% to 8% of all emergency department visits. The diagnosis depends on clinical manifestation, radiological findings, and surgeon experience. Appendicitis causing pain in the left lower quadrant is rare and can occur with congenital abnormalities that include a true left-sided appendix or as an atypical presentation of a right-sided, but long appendix, which projects into the left lower quadrant. Left-sided acute appendicitis develops in association with two types of congenital anomalies: situs in versus and mid-gut malrotation. Here we are reporting a case of right-side lower quadrant pain presentation of left appendicitis with partial situs inversus. A 28-year-old male presented to the emergency department with a one-day history of right lower quadrant (RLQ) abdominal pain associated with nausea and vomiting. Physical examination revealed RLQ abdominal tenderness with localized guarding. Laboratory tests revealed raised levels of C-reactive protein and neutrophilic leukocytosis. Abdominal ultrasound report came as non-visualized appendix. Patient was taken for laparoscopic appendicectomy where the appendix was not found on the right iliac fossa. Laparoscopic exploration was done and revealed a swollen inflamed left-sided appendix attached to a healthy mobile left sided caecum. Laparoscopic appendicectomy was carried out and the postoperative period was uneventful and the patient was discharged within 24 hours. Postoperative chest and abdominal contrast-enhanced computed tomography showed a situs inversus with levocardia. Left-sided appendicitis is a rare condition characterized by the anatomical variation of the appendix with atypical presentation and is therefore easy to misdiagnose. Preoperative clinical diagnosis of left sided acute appendicitis is difficult and imaging may help determine the correct diagnosis. Laparoscopic appendicectomy is far more superior to the open method in these cases as it saves the patient a formal open surgical exploration.