A 38-year-old male presented with left-sided hydrocele and indirect inguinal hernia of long duration. His medical history included repeated upper respiratory tract infection requiring frequent hospitalization in childhood and was diagnosed to have a ventricular septal defect (VSD) and situs inversus at the age of 7 years. On examination, the apical impulse was felt in right 5th intercostal space with right precordial bulge. A holosystolic murmur (Grade 3/6) was heard in the right 2-4th intercostal spaces with a loud P2 and normal vesicular breath sounds. The hemoglobin of 16.3 g/dl and platelets of 2,30,000/mm3 were noted on blood investigations. Chest X-ray showed dextrocardia and a right-sided “stomach bubble” []. Situs inversus of abdominal organs was seen on the ultrasound. Echocardiogram (ECHO) revealed dextrocardia, subaortic VSD, mildly dilated right ventricle and atrium, moderate tricuspid regurgitation, and pulmonary arterial hypertension (60 mmHg). ECG was consistent with mirror image dextrocardia.\nA combined spinal epidural anesthesia (CSEA) was planned for hernioplasty and hydrocelectomy. The patient was premedicated with pantoprazole and ondansetron on the morning of surgery. A 20G arterial line was secured for invasive pressure monitoring. Continuous ECG, invasive blood pressure, and pulse oximeter was instituted. With strict asepsis and the patient in sitting position, an 18-gauge epidural catheter was placed at L1-L2 interspace. Using a 25-gauge spinal needle, subarachnoid block was performed with 1.8 ml of 0.5% bupivacaine and 25 μg fentanyl at L3-L4 interspace. The patient's heart rate, blood pressure, and oxygen saturation remained stable during the intraoperative period. Fentanyl 50 μg and graded doses of 0.2% Ropivacaine was administered epidurally to achieve segmental anesthesia for the subsequent operative period. Further intraoperative course was uneventful. In the first 24 hours postoperatively, patient was monitored in the ICU. Buprenorphine 120 mcg twice daily was administered for epidural analgesia. Further postoperative period was uneventful and subsequently, the patient was discharged home.
A 55-year-old female patient presented to surgical out-patient department (OPD) with chief complaints of pain and left hypochondrium for the last 3 days accompanied by nausea and vomiting. She presented a big dilemma to the attending surgeon as all the clinical signs and symptoms pointed towards symptomatic cholelithiasis, but the pain in the left hypochondrium totally contradicted the diagnosis. It was only with the help of radiological investigation reports that we were able to confirm it as a case of situs inversus totalis. Her chest X-ray typically depicted dextrocardia and spiral computed tomography (CT) scan showed transposition of all major abdominal organs. Echocardiography was carried out and revealed normal cardiac parameters with an ejection fraction of 60%.\nPre-anaesthetic evaluation revealed Mallampatti class II patient with a slight retrognathia, a pulse rate of 74/min, blood pressure of 130/78 mmHg and normal profile of laboratory investigations. She had a history of intermittent respiratory tract infections, especially during the winter season. At present, the patient had no systemic complaint pertaining to any organ system except for the gall bladder disease. A decision to operate the patient was taken and she was posted for open cholecystectomy.\nTablet ranitidine 150 mg and tablet alprazolam 0.25 mg were administered as premedication a night before and 1 h prior to the surgical procedure with a sip of water. In the operation theatre, a good intravenous (IV) access was secured with a wide bore cannula. Induction of anaesthesia was achieved with O2, isoflurane, propofol 120 mg, butorphanol 1 mg and succinylcholine 100 mg. During induction, we encountered masseter spasm immediately after the administration of succinylcholine, which lasted for approximately 45 s, and disappeared spontaneously, but we were able to ventilate the patient with bag and mask during this episode. Intubation was extremely difficult as the larynx was placed quite anteriorly and the laryngoscopic view could be best labelled as Cormack Lehane grade-III. Maintenance of anaesthesia was carried out with injection vecuronium and low concentration of isoflurane in oxygen and nitrous oxide mixture. The peri-operative period was characterized by frequent copious secretions from the respiratory tract that had to be cleared regularly for smooth ventilation. Inj. Hydrocortisone 100 mg was given prophylactically to prevent any bronchospasm. The surgical procedure was smooth and uneventful, and lasted for about 1 h. At the end of surgery, inj. Neostigmine and glycopyrrolate were administered but extubation was delayed as the patient developed prolonged post-operative apnoea. Therefore, extubation was performed only after establishing the return of all protective airway reflexes and establishment of regular breathing pattern. Infiltration of surgical incision site was carried out with 8 ml 0.375% of ropivacaine. The recovery period and hospital stay were uneventful and the patient was discharged in a satisfactory condition on the eighth post-operative day and was called for follow-up after 2 weeks.