Sir,

Anomalous situation of vermiform appen­dix in cases of situs inversus or mairotation of midgut has an incidence of 1 in 35,000¹ cases. Acute appendicitis in this condition usually poses diagnostic problem. Such a case was encountered in Civil Hospital, Haripur where a 38 years old female presented with vomiting and diffuse paraum­blical pain which later shifted to the right iliac fossa. On examination temperature was 99.5°F, pulse 100/min and tongue was coated. Abdomen was tender all over with point of maximum tenderness in right iliac fossa. Provisional diagnosis of acute appendicitis. was made for which she underwent surgery. Through right grid iron incision caecum could not be localized, instead sigmoid colon was found in right iliac fossa. Incision was extended to confirm the anomaly and right lobe of the liver was missing from its usual site and inflammed appendix were found in left iliac fossa. Appendicutomy was done through an incision in the left iliac fossa. Post operation chest X-ray and cholecystogram confirmed situs inversus Preoperative diagnosis of situs viscerum inversus is made in just over 40% cases², with point of maximal tenderness in 37% cases. Probable explanation is that in situs inversus components of the nervous system are spared from reversal³, therefore referred pain may be located on the iight side.

Tariq Mufti
Department of Surgery, Surgical Unit \'B\', Civil Teaching Hospital, Abbottabad.

1. Baily & Love’s Short Practice of Surgery, Ed: Rains A.J.H, and Ritchie H.D., H.K. Lewis & Co. London, 1977, P. 1026.
2. Blegan, H.M. Surgery in Situs inversus. Ann. Surg., 1949; 129: 244.
3. Cockayne, E.A. Situs inversus. Q.J. Med., 1938; 7:479.