|Year : 2015 | Volume
| Issue : 2 | Page : 272-278
Laparoscopic cholecystectomy in situs inversus totalis: Two case reports with review of literature
Sunder Goyal1, Aditya Garg1, VK Singla2
1 Department of Surgery, Kalpana Chawla Govt. Medical College, Karnal, Haryana, India
2 Department of Surgery, Karnal Nursing Home, Karnal, Haryana, India
|Date of Web Publication||16-Dec-2015|
Department of Surgery, Kalpana Chawla Govt. Medical College, Karnal, Haryana
Source of Support: None, Conflict of Interest: None
Situs inversus totalis is a rare congenital anomaly characterized by transposition of organs to the opposite site of the body. Diagnosis and treatment of cholelithiasis in such cases pose a challenge to operating surgeon because of atypical clinical picture and due to the contra lateral disposition of the visceral organs. No doubt, laparoscopic cholecystectomy in these patients is technically more demanding still it is feasible and should be done by trained and experienced laparoscopic surgeon. Difficulty is encountered in skeletonizing the cystic duct and cystic artery in Calot's triangle, which requires extra time than normally located gall bladder.
Keywords: Cholelithiasis, laparoscopic cholecystectomy, situs inversus totalis
|How to cite this article:|
Goyal S, Garg A, Singla V K. Laparoscopic cholecystectomy in situs inversus totalis: Two case reports with review of literature. Arch Med Health Sci 2015;3:272-8
|How to cite this URL:|
Goyal S, Garg A, Singla V K. Laparoscopic cholecystectomy in situs inversus totalis: Two case reports with review of literature. Arch Med Health Sci [serial online] 2015 [cited 2020 Aug 9];3:272-8. Available from: http://www.amhsjournal.org/text.asp?2015/3/2/272/171921
| Introduction|| |
Situs inversus totalis (SIT) is a rare clinical entity and was first reported by Fabricius in 1600.  It is a rare congenital anomaly with an autosomal recessive genetic pattern of inheritance, and the genetic defect mostly occurs within the 2 nd week of embryonic life. Incidence is almost equal in both genders.  Usually, it is asymptomatic through adulthood unless accompanied by cardiac problems. The incidence is thought to be in the range of 1:10 000-1:20 000.  It can be associated with Kartagener triad (bronchiectasis, sinusitis, and situs inversus) and cardiac anomalies. There is no evidence for higher incidence of cholelithiasis in SIT.  Mouret performed first laparoscopic cholecystectomy in 1987.  No doubt, laparoscopic cholecystectomy in these patients is technically challenging and requires proper orientation of the left upper quadrant.  Still it is widely accepted as the treatment of choice for symptomatic cholelithiasis in patients with situs inversus.  Herein, we present 2 cases of laparoscopic cholecystectomy in SIT.
| Case Report|| |
A 52-year-old female patient presented with a history of recurrent pain in left upper quadrant of the abdomen. Pain use to be aggravated by heavy meals. There was a history of abdominal hysterectomy 4 years back. She was a known case of diabetes mellitus type II. X-ray chest [Figure 1] and ultrasound of the abdomen [Figure 2] confirmed the diagnosis of SIT and gall stones. All laboratory investigation including liver functions were normal. Coagulation profile was normal, which excluded the hematological causes of gall stone in such age group. Laparoscopic cholecystectomy was done as per technique described below. Postoperative picture is shown as [Figure 3]. The procedure took 60 min, and there was minimal blood loss. Our patient had an uneventful postoperative course and was discharged on the 3 rd postoperative day. Pathologic examination confirmed cholelithiasis with chronic cholecystitis. The patient was followed-up and has remained well up to 1-year.
A 50-year-old female presented with a history of pain in epigastrium and right hypochondrium for the last 10 months. There was a history of radiation to the back also. Pain use to be aggravated by heavy meals. X-ray chest, ultrasound of the abdomen and computed tomography (CT) [Figure 4] confirmed the diagnosis of SIT and gall stones. All laboratory investigation including liver functions were within normal range. Coagulation profile was normal which excluded the hematological causes of gall stone. Laparoscopic cholecystectomy was done as per technique described below. Postoperative photo is shown as [Figure 5] [Figure 6] [Figure 7]. The procedure took 50 min, and there was minimal blood loss. Our patient had an uneventful postoperative course and was discharged on the 2 nd postoperative day. Pathologic examination confirmed cholelithiasis with chronic cholecystitis. The patient was followed-up and has remained well after 3 months.
| Discussion|| |
Situs inversus totalis is a rare clinical entity and was first reported by Fabricius in 1600.  The incidence is thought to be in the range of 1:10 000-1:20 000.  Incidence of gallbladder (GB) stone disease is same in SIT and normal patients. , Due to the contralateral disposition of the viscera, the diagnosis and surgical approach of these patients may pose a diagnostic dilemma. Most patients presented with left-sided upper abdominal or epigastric pain (30%). However, about 10% of patients with left-sided cholelithiasis present with right-sided abdominal pain.  As the central nervous system may not share in the general transposition, this phenomenon has been observed for both visceral biliary pain and somatic pain in cases of cholecystitis. 
A high index of suspicion is important for diagnosis and proper treatment thus avoiding mishaps in patients with situs inversus. Situs inversus is suspected clinically if the heart beat is in the right fifth intercostals space, the liver dullness is on left-side, and the right testicle hanging lower than the left.  Ultrasonography, abdominal CT, chest scan, and magnetic resonance imaging will confirm the presence of visceral transposition. ,
About 40 cases of open cholecystectomy and 71 cases of laparoscopic cholecystectomy in patients with SIT have been reported in the literature so far. ],[],[],[],[],[],[[13 ]],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[],[
Laparoscopic surgery has become gold standard for treatment of gallstones due to undisputed-advantages like (1) small incision (2) lesser postoperative pain (3) minimal bowel handling and early bowel movement (4) early return to work (5) scar less surgery and better cosmesis. Single incision laparoscopic surgery further adds all these advantages. Various port positions are four ports, three ports, and single-port.
The most challenging factor for performing laparoscopic cholecystectomy in patients with situs inversus is the "mirror image" anatomy. This uninvited condition, together with the two-dimensional effect of laparoscopy may lead to some problems in orientation and dissection during the procedure with the possibility to high-risk of iatrogenic injuries. 
Usual difficulties encountered during this surgical procedure:
Well defined and careful dissection at the Calot's triangle results in safe skeletonization of cystic duct and artery. For right-handed surgeon, it is useful to reach the anatomy in terms of "medial" and "lateral" relations, rather than "left" and "right" since the medial and lateral relations in situs inversus are preserved. Right hand dominated surgeons can rearrange may ports position to perform dissection and clip application as we did in our 2 nd case. We used 10 mm port at mid-clavicular line instead of standard 5 mm port to apply clip.
- Due to unusual anatomy, there are chances of iatrogenic injury.
- Dissection is difficult for right-handed surgeons and easy for left-hander surgeons.
- Common bile duct is located on right-side of Calot's triangle, not on the left-side, and this should be constantly be kept in mind during dissection.
- Most important and difficult part of surgery is clip application.
Right-dominated surgeon can slightly bend their body to dissect the structure of Calot's triangle using their right hand in the epigastric port while allowing their assistant to retract Hartmann's pouch.
Other way is that the lateral ports can be moved slightly caudally, and the dissecting hand can be placed in one of those ports, while the left hand retracts the GB fundus through the epigastric port. Per-operative-cholangiogram is done by few surgeons to define ductal anatomy of Calot's triangle. 
In the English-language literature, we found many reports of successful laparoscopic cholecystectomy with SIT. However, reported single-incision laparoscopic cholecystectomy cases are limited. No natural orifice transluminal endoscopic surgery procedure for cholecystectomy in the patient with SIT has reported yet. In an effort to reduce morbidity and improve the cosmesis single-port laparoscopic cholecystectomy has recently emerged, where the surgery is done through a single-port, typically the patient's navel. This improves the cosmesis, lessens postoperative pain and ensures virtually a "scar less" surgery. ,,,,,,, Although the single-port or single-incision procedures are cosmetically more approvable, technically they are slightly more time-consuming and more difficult and costly procedures. In few cases single-port was created through the umbilicus.
This technique was named as single-port access surgery. In a meeting held in July of 2008, the single-port consensus reviewed all the terms used for laparoscopic or endoscopic procedures performed through a single incision in the abdomen and projected that laparoscopic single-site surgery (LESS) be used as the common term to define the process LESS technique basically include two different types of surgery. In the first one, a single-incision is made to place multiple trocars. In the second, a single incision is made to place a single trocar designed to contain all instruments. There are many models of single-port devices from many industries. SITRACC (Edlo, Porto Alegre, Brazil), Tri-port (Advanced Surgical Concepts, Wicklow, Ireland), X-Cone (Karl Storz, Tuttlingen, Germany) and SILS (Covidien Mansfield, USA). 
Lochman et al.  did laparoscopic cholecystectomy upon a 75-year-old female with gallstones with acute cholecystitis with four ports technique. Less than 40 "open" cholecystectomies were published in the prelaparoscopic cholecystectomy era.  To overcome the difficulties with dominant right hand by changing right and left hand for dissection means use of right hand from the left sub-costal port to dissect cystic duct and artery, or the right hand is used to do skeletonization of cystic duct and artery through epigastric port while the first assistant holds the fundus and retract Hartmann's pouch.
Demiryilmaz et al.  reported 2 cases of laparoscopic cholecystectomy in situs inversus. No racial or gender predilection is present. They have concluded that vision with 30° camera is better.
Arya et al.  operated on a 35-year-old female of cholelithiasis with situs inversus. He used standard four ports. Surgeon did dissection of Calot's triangle through epigastric port while first assistant retracted the Hartmann's pouch. Clipping was also done through epigastric port. Thus right-handed surgeon has to modify the technique for proper hand eye coordination.
Salama et al.  did laparoscopic cholecystectomy on a 10-year-old boy with situs inversus. He used standard four ports. He reviewed 50 cases of laparos1copic cholecystectomy.
Raghuveer et al.  used the standard ports position on left-side instead of right-side while operating upon a 55-year-old male. Dissection of Calot's triangle was carried out by standing on the caudal side of patient with the patient in Lloyd-Davis position. There were no complications. They have reported 37 cases of laparoscopic cholecystectomy without any complications. In there study most cases were females and within the age group 20 and 80 years. According to this study, epigastric pain was reported in 30% of cases and in 10% of cases, pain was located in right upper quadrant. According to this study, the mirror image anatomy poses difficulty in orientation while performing surgery. If the surgeon is right handed, then Hartmann's pouch can be retracted by assistant and thus surgeon can operate in ergodynamic manner.
Moirangthem et al.  operated upon a 50-year-old female who presented with pain in left upper quadrant, which radiated to left scapular region. They also used four ports standard position on left-side. To perform surgery in an ergonomic fashion and to avert complications, Calot's triangle dissection clipping was carried out with right hand through epigastric port. They used harmonic scalpel to perform the surgery. Total operating time was 75 min. Drain was used. According to all studies, the anatomical variations and reverse disposition of the biliary tree needs an accurate and careful skeletonizaion of cystic duct and artery to avoid iatrogenic complications. Left-handed surgeons are comfortable while the dissection as using the nondominate left hand can be dangerous as clips may slip if it is loose.
Han et al.  performed first case of single incision multiport laparoscopic cholecystectomy in situs inversus patient in year 2011 without any complications. Major advantage of the technique is better cosmetic results obtained in the absence of obvious abdominal scarring. The most important problem in SILS application is the difficulty, experienced by the surgeon in adaptation to new instruments. Surgeon and assistant usually interfere with each other. Some of these disadvantages of the technique can be removed using semi-flexible camera systems and cross-angled hand devices. Despite these restrictions of SILS, we could successfully perform our operation in the case with SIT in an appropriate period.
Khiangte et al.  used a 2.5 cm completely intra-umbilical, vertical skin incision to perform surgery in a 65-year-old man. Laparoscopic cholecystectomy was done in SIT with the telescope inserted via the E.K. glove port in the umbilicus performed. He has reviewed laparoscopic cholecystectomy done with a single incision as shown in [Table 1].
|Table 1: Publications on situs inversus and single port/single incision cholecystectomy|
Click here to view
Surgeons have done even appendicectomy, common bile duct exploration and gastric banding along with cholecystectomy in patients with SIT. ,, SIT patients are more prone to conversion as there are increased possibility of associated biliary tract and vascular anomalies.  Cardiac anomalies are also common in patients with situs inversus.
Rate of conversions to open surgery and major complications are comparable with laparoscopic cholecystectomy in normal gallstone patients.
How to reduce iatrogenic complications:
Future recommendations 
- Creation of all ports in an ergonomic fashion.
- Position of operating surgeon on caudal end with Lloyd-Davis position.
- Allowing the first assistant to retract the Hartmann's pouch.
- Always dissection above Rouviene's sulcus.
- Convert to open whenever in doubt of anatomy.
Following aspects of laparoscopic cholecystectomy in situs inversus patients are valuable and worth mentioning in the end.
- Laparoscopic cholecystectomy is can be performed even in empyema of GB in SIT patients.
- Reverse anatomy is responsible for the difficulty in diagnosis and orientation during laparoscopic cholecystectomy, so, an experienced surgeon should do this procedure.
- Preoperative appraisal of abnormalities vascular anatomical structures is essential and can be done with CT angiogram.
- Usually, laparoscopic cholecystectomy in situs inversus will require extra time due to reverse anatomy.
- As left handed surgeon is used to perform laparoscopic cholecystectomy on right-sided GB, he may also encounter difficulty in situs inversus patients.
- Robotics may reduce these difficulties during laparoscopic cholecystectomy in situs inversus totalis patients.
| Conclusion|| |
No doubt, changes in anatomical disposition of organ influence the diagnosis due to atypical clinical picture; still laparoscopic cholecystectomy is feasible and can be performed in gallstones with severe infection like empyema with SIT patient with complications comparable with laparoscopic cholecystectomy in normal gallstone patients. It is essential to rule out vascular anatomical variations preoperatively, and it may need CT angiogram. Robotics may prevent difficulties in future.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]