Single-Incision Multi-Port Appendectomy for a Patient with Situs Inversus Totalis First case report

Situs inversus totalis (SIT) is a rare autosomal recessive condition involving the complete lateral transposition of the organs. When individuals with this condition suffer from appendicitis, associated pain and symptoms are usually present on the left side, resulting in diagnostic difficulties. Moreover, the laparoscopic removal of the left-sided appendix may pose practical problems during surgery. Removal of an inflamed appendix is generally performed using a multiple-port laparoscopy. We report a 22-year-old male who presented to the Lifeline Institute of Minimal Access Surgery in Chennai, India, in April 2015 with pain in the left iliac fossa. Chest X-rays and ultrasonography confirmed SIT with an acutely inflamed appendix on the left side. The patient underwent a single-incision multi-port laparoscopic appendectomy with a successful outcome. To the best of the authors’ knowledge, this is the first report in the literature of a single-incision multi-port appendectomy in a patient with SIT.

The patient suffered from loss of appetite and vomiting.A physical examination revealed that the patient was mildly tachycardic, febrile and had severe localised tenderness in the left iliac fossa in addition to rebound tenderness and abdominal guarding.When asked for his medical history, the patient informed the physician that his heart was on the other side.A chest X-ray and ultrasound confirmed the diagnosis of SIT with an acutely inflamed appendix in the left iliac fossa.Consequently, a single-incision multi-port appendectomy was performed.
A thorough laparoscopy of the internal organs was performed using a telescope inserted through a supraumbilical incision of 10 mm, including an examination of the terminal 90 cm section of the ileum in the small bowel.The inflamed appendix was observed along the left paracolic gutter.A second port was introduced by extending the incision by an additional 5 mm and inserting a 5 mm trocar directed towards the left iliac fossa, away from the lateral edge of the incision [Figure 1A].The appendix was gently lifted up using alligator needle/grasper forceps (Alligator ™ Retrieval Device, Medtronic, Fridley, Minneapolis, USA) [Figure 1B].The appendix was coiled upon itself and was carefully released [Figure 2A].A small amount of purulent fluid was removed from the left iliac fossa by suctioning.An ultrasonic scalpel was used to dissect the complete mesoappendix, with the alligator needle/ grasper forceps elevating the shaft of the appendix.Two ENDOLOOP ® ligatures (Ethicon Inc., Johnson & Johnson, Somerville, New Jersey, USA) were looped around the appendix from the port with the support of the alligator needle/grasper forceps [Figure 2B].For the third tie, a cobbler's suture needle was used to suture the appendix base through the needle hole of the alligator needle/grasper forceps with dissecting forceps (Laparoscopic Maryland Dissecting Forceps, Medline Industries Inc., Mundelein, Illinois, USA) in the port.The appendix was cut between the ties.The fluid was suctioned out and the appendix was removed through the incision from the lateral port with camera assistance.The patient made a smooth postoperative recovery and was healthy at a 20-day follow-up.appendix through the port.Additionally, detailed examination of the terminal end of the small bowel was possible using solely the bowel-holding forceps in the port.Several reports have recommended alligator needle/grasper forceps in single-port or reducedport cholecystectomies .11,19Using the alligator forceps in one hand and the energy device (e.g.harmonic scalpels, monopolar or bipolar electrosurgical devices or electrocautery devices) in the other also reduces the potential triangulation problems that may arise during a single-port surgery.In the present case, a cobbler's needle was used to suture the appendix base through the needle hold of the alligator needle/grasper forceps with dissecting forceps in the port.This type of intracorporeal suturing is usually deployed in single-port fundoplication surgeries and single-port sleeve gastrectomies. 4 Despite concerns regarding triangulation, the authors would recommend the combination of alligator needle/grasper forceps and a 10 and 5 mm port through the same incision.
Although two ports were used in the current case, both ports were implanted through a single 15 mm incision; the most accurate term for this procedure is therefore a single-incision double-port appendectomy.The alligator needle/grasper forceps and the cobbler's needle were both passed through a single needle hole of 1.5 mm in diameter, justifying the use of the aforementioned term.Although a singleport device might have facilitated the handling and removal of the appendix, it is departmental policy at the Lifeline Institute of Minimal Access Surgery to perform single-incision multi-port surgeries so as to decrease patient costs.

Conclusion
A single-incision appendectomy is a viable alternative to multi-port appendectomies in patients with SIT.To the best of the authors' knowledge, this is the first case to be reported in the English medical literature.

Discussion
Appendectomies among SIT patients have previously been reported, with 69 cases to date in the scientific literature. 5When patients with SIT present with acute appendicitis, the diagnosis can be confusing. 6,7n cases of a straightforward and total contralateral transposition of the viscera, the appendix and caecum can easily be identified on the left side.However, in patients with malrotation of the viscera, the appendix may be in the subhepatic or subsplenic positions which can cause diagnostic problems during surgery. 8isconcertingly, up to 15% of SIT patients with appendicitis report pain on the right side. 3 A small proportion of those without neural situs inversus complain of appendicular pain on the right side as well. 5,7,9,10This anomaly occurs due to a failure in the transposition of the nervous system, with the leftsided appendix still causing right iliac fossa pain.As a result, ultrasonography or computed tomography should be performed to confirm the diagnosis of SIT, as was done in the present case.

Figure 2 A&B:
Figure 2 A&B: Intrasurgical photographs of (A) the coiled and inflamed appendix in the left iliac fossa of a patient with situs inversus totalis and (B) the looping of the ligature around the base of the appendix.