Left Side Appendicitis with Midgut Malrotation in an Adult
A 37-year-old man was admitted at the emergency unit of our hospital with acute abdominal pain, which started the previous night. Patient's history revealed no previous illness or surgery. Pain was diffused, with tenderness mainly in upper left quadrant, and the temperature was 37.5°C. Laboratory tests showed an elevated blood cell count (15,000) with normal C-reactive protein. A diagnosis of peritonitis was suspected, either by perforated gastroduodenal ulcer or diverticulitis. Contrast-enhanced abdominal computed tomography showed acute left side appendicitis with midgut malrotation [Figure -]. Appendix was enlarged, with a transverse diameter measured to 13 mm, associated with four stercoliths visualized in the plane of the left renal vein. The entire small bowel was found in the left half of the abdomen and the entire colon was found in the right half. The superior mesenteric vein (SMV) was to the left of the SMA rather than in the normal right ventral position. The patient was planned for surgery and a laparotomy was performed. Surgical findings confirmed the severe inflammation of the appendix and the ileocecal region(s) located in the left quadrant. A Ladd's procedure was performed, including derotation of the bowel, appendectomy, division of the mesenteric bands lying across the duodenum from cecum to right upper quadrant, widening of the base of the mesentery, taking down the ligament of Treitz, moving the duodenum to the right, and finally returning the bowel to a position of nonrotation with the cecum placed into the left upper quadrant []. The patient was discharged on the seventh postoperative day with no complication.