Laparoscopic Cholecystectomy in Situs Inversus Totalis

Abstract

A 55-year-old gentleman known case of situs inversus totalis presented with dull aching type of pain in the upper abdomen more in the epigastrium and non radiating. It was associated with fullness of stomach and dyspepsia.On examination no jaundice or pyrexia was noted. Apex beat was on the right fifth intercostal space in the mid clavicular line. WBC counts and amylase levels were normal. USG abdomen [Table/ Fig-1] revealed left sided gallbladder with multiple calculi. There was no evidence of common bile duct or intrahepatic biliary radicals dilatation.Situs inversus totalis was confirmed with ECG [Table/ Fig-2] showing right axis deviation. Global negativity in lead I (a negative P-wave, QRS complex and T-wave). Positively deflected QRS complex in aVR. Negative P-wave in lead II. Reverse R-wave progression in precordial leads.The leads were placed in opposite direction and repeat ECG was obtained [ There were no comorbid conditions. Laparoscopic cholecystectomy was planned after obtaining a valid informed written consent. The operating set up and the monitor were placed in the direction opposite to conventional surgery. The operating team also changed their positions, primary surgeon and first assistant were standing on the right side and second assistant was standing on the left side.Under general anaesthesia on insertion of 10mm thirty degree storz system telescope camera all the contents were exactly found on the opposite side [Table/ Fig-7],10mm epigastric port was put and two 5mm ports were put in midaxillary and anterior axillary line on left side [Table /Fig-8]. The primary operating surgeon was right handed.He had to crossover his arms to retract the neck of the gallbladder with left hand and dissect the callot's with right hand. To prevent this difficulty the first assistant was asked to retract the neck of gallbladder [1] and the primary surgeon dissected out the callots triangle with right hand [1]. Surgery Section ABSTRACTSitus inversus totalis is a rare condition where the organs in the body is placed in the opposite side. When such patient presents with the diseases of the intra abdominal organs the diagnosis is challenging and the operative procedure to be performed will be difficult. This may require the anticipation of variations in anatomy, ergonomic changes required during surgery and mastery over the operative skills in reversed anatomy. Cholelithiasis in situs inversus totalis is one such situation. Herein we report a case of situs inversus totalis who underwent successful laparoscopic cholecystectomy for symptomatic gallbladder calculi.

Laparoscopic Cholecystectomy for Acute Cholecystitis in Situs Inversus Totalis: An Extraordinary Approach

“…The pain can spread toward the left shoulder or lower scapula. Even the gall bladder is localizated on the left side and 10% of the patients may have pain in the right side of the abdomen (8). Our patient experienced pain in the epigastric region, which spread toward the left side.…”

Laparoscopic cholecystectomy in patients with situs inversus totalis: case report and review of reported surgical techniques

“…Medline (via Pubmed) "situs inversus"[MeSH] or "situs" AND "inversus" or 131 73 "situs inversus" and "cholecystectomy"[MeSH] or "cholecystectomy" support higher rate of biliary or vascular injury or, conversion to an open surgery during laparoscopic cholecystectomy in patients with SIT but, utmost precaution should be taken in handling cases of SIT. Patle et al [9] Right Lithotomy Infraumblical 5 mm left 10 mm 5 mm left 65 mins midclavicular epigastric anterior axillary Salama et al [10] Right Supine Infraumbilical 10 mm epigastric 5 mm left 5 mm left midclavicular anterior axillary Arya et al [11] Right Reverse Infraumbilical 10 mm epigastric 5 mm left 5 mm left 95 mins trendelenburg left to midline midclavicular anterior axillary Ali et al [12] Right -Infraumbilical 10 mm left 5 mm right 5 mm left 70 mins midclavicular midclavicular anterior axillary RaghuveeR et al [13] Right Lloyd-Davies Infraumbilical 10 mm epigastric 5 mm right 5 mm left 135 mins midclavicular anterior axillary Ahmed et al [14] Right -Supraumbilical 5 mm left 10 mm left 5 mm left 48 mins midclavicular paramedian anterior axillary 5 cm caudally from xiphoid Fanshawe et al [15] Right Lloyd-Davies 10 mm left 5 mm left 5 mm supra-5mm subxiphoid 60 mins midclavicular subcostal umbilical Alam et al [16] Right Reverse Infraumbilical 10 mm 5 mm left 5 mm left 70 mins trendelenburg subxiphoid midclavicular anterior axillary Alsabek et al [17] Left -Infraumbilical 10 mm 5 mm left 5 mm left 60 mins subxiphoid midclavicular anterior axillary…”