Situs Inversus Totalis and Anesthesia: Challenging aspects

Ruma Thakuria^* and Ajay Singh
^*Correspondence: Ruma Thakuria, Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India, Tel: 7838689025, Email:

Keywords

Situs inversus totalis; Dextrocardia; Cholecystectomy

Introduction

Situs inversus totalis is a congenital condition characterized by transposition of abdominal viscera. Majority of thoracic and abdominal visceral organs are reversed or mirrored from their normal position [1]. It is generally an autosomal recessive disorder, and sometimes may be X chromosome-related. The incidence was reported as 1 in 5000-20000 live births [2-4]. Most of the patients with situs inversus totalis remain asymptomatic throughout their lifetime [4]. It is imperative to diagnose the commonly presenting abdominal pathology properly as the reverse position of visceral organs may mask the classical clinical findings. Radiological diagnosis (ultrasonography, computerized tomography, chest radiograph) plays the key role for confirmation of situs inversus totalis. We report the anesthetic management of situs inversus totalis in a 26 years old female who presented with symptomatic cholelithiasis for laparoscopic cholecystectomy.

Case Report

26 years, 58 kg, young female presented with pain abdomen over left hypochondrium associated with nausea, vomiting, and dyspepsia for 3 months. Apart from this, there were no other symptoms. On ultrasonography abdomen and Computerized Tomography (CT) of the chest and abdomen, the patient was found to have dextrocardia with situs inversus totalis and left-sided cholelithiasis. The patient was posted for laparoscopic cholecystectomy.

On preoperative check-up, the patient ’ s vital parameters and biochemical parameters were within the normal limits. On auscultation, heart sounds were heard on right 5th intercostal space. A 12 lead Electrocardiograph (ECG) showed inverted T-wave in lead V1 to V6 chest leads (Figure 1). A chest X-ray confirmed the presence of dextrocardia (Figure 2). Echocardiography revealed dextrocardia with mild aortic regurgitation and normal left ventricular ejection fraction. Pulmonary function test was within normal limits. On airway examination, she had anticipated difficult airway with Mallampati grade IV and short neck. The patient was premedicated with tablet ranitidine and alprazolam.

In the operation theatre, all standard monitors were connected and intravenous access was secured with the 18G cannula. For ECG monitoring, the electrodes were placed in a reversed position. Induction of anesthesia was achieved with Fentanyl 2 μg/kg, Propofol 2 mg/kg and Succinylcholine 1 mg/kg followed by tracheal Intubation with 7.5 mm internal diameter endotracheal tube, and the position were confirmed. Mechanical ventilation maintained with volumecontrolled mode with oxygen: nitrous oxide and isoflurane to maintain minimum alveolar concentration 0.8-1.0. We noticed a prolonged effect of muscle relaxant for 35 minutes after succinylcholine administration which was confirmed with Neuromuscular Transmission (NMT) Monitoring. Further, during surgery, relaxation was maintained with Atracurium. Peak airway pressures were closely monitored throughout surgery. At the end of the surgery, residual neuromuscular blockade was reversed with Neostigmine and Glycopyrrolate and the trachea was extubated. The procedure was uneventful, the patient recovered satisfactorily and shifted to the Post- Anesthesia Care Unit (PACU).

Discussion

We presented safe and successful anesthetic management of laparoscopic cholecystectomy with situs inversus totalis. However, prolonged duration of muscle relaxation occurred after succinylcholine use which may signify increased sensitivity to depolarizing muscle relaxant. The plasma butyrylcholinesterase activity level could not be measured in the indexed patient in the postoperative period due to the patient and relative refusal. There are few case reports documenting prolong the effect of succinylcholine in a situs inversus totalis patient [5]. Co-existing anomalies of other vital organs also have to be taken under consideration like cardiovascular anomalies, e.g. Tetralogy of Fallot, Atrial septal defect, ventricular septal defect; digestive system anomalies e.g. duodenal stenosis, anal atresia; respiratory system anomalies e.g. sinusitis, bronchiectasis [4]. The triad of situs inversus totalis, sinusitis, and bronchiectasis is called Kartagener's syndrome [6]. Dwarakanath S, et al. [7] has described an association of adultonset occult spinal dysraphism along with situs inversus totalis. Although co-existing abnormalities of other organs are more common than in general population, most patients with situs inversus have no symptoms and complications [4] The most important challenging aspects of anesthesia in such cases has been discussed in following table (Table 1).

Conclusion

To conclude, patient with situs inversus totalis posted for noncardiac surgery makes the anesthetic management challenges. Though proper history taking, general examination, and preoperative preparation are imperative for safe anesthesia conduction, an undue prolong the effect of depolarizing muscle relaxant should always be taken under consideration.

References

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