|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 2019 Jun 20];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.
| References|| |
Yaghan RJ, Gharaibeh KI, Hammori S. Feasibility of laparoscopic cholecystectomy in situs
inversus. J Laparoendosc Adv Surg Tech A 2001;11:233-7.
Bozkurt S, Coskun H, Atak T, Kadioglu H. Single incision laparoscopic cholecystectomy in situs
inversus totalis. J Surg Tech Case Rep 2012;4:129-31.
Al-Jumaily M, Hoche F. Laparoscopic cholecystectomy in situs
inversus totalis: Is it safe? J Laparoendosc Adv Surg Tech A 2001;11:229-31.
Crosher RF, Harnarayan P, Bremner DN. Laparoscopic cholecystectomy in situs
inversus totalis. J R Coll Surg Edinb 1996;41:183-4.
Jaffary B. Minimally invasive surgery. Arch Dis Child 2005;90:537-49.
Machado NO, Chopra P. Laparoscopic cholecystectomy in a patient with situs inversus totalis: Feasibility and technical difficulties. JSLS 2006;10:386-91.
Khiangte E, Newme I, Patowary K, Phukan P. Single-port laparoscopic cholecystectomy in situs
inversus totalis using the E.K. glove port. J Minim Access Surg 2013; 9:180-2.
Campos L, Sipes E. Laparoscopic cholecystectomy in a 39-year-old female with situs inversus. J Laparoendosc Surg 1991;1:123-5.
Takei HT, Maxwell JG, Clancy TV, Tinsley EA. Laparoscopic cholecystectomy in situs
inversus totalis. J Laparoendosc Surg 1992;2:171-6.
Sato M, Watanabe Y, Iseki S, Akehi S, Tachibana M, Sato N, et al.
Hepatolithiasis with situs inversus: First case report. Surgery 1996;119:598-600.
Schiffino L, Mouro J, Levard H, Dubois F. Cholecystectomy via laparoscopy in situs
inversus totalis. A case report and review of the literature. Minerva Chir 1993;48:1019-23.
Bedioui H, Chebbi F, Ayadi S, Makni A, Fteriche F, Ksantini R, et al.
Laparoscopic cholecystectomy in a patient with situs inversus. Ann Chir 2006;131:398-400.
Salama IA, Abdullah MH, Houseni M. Laparoscopic cholecystectomy in situs
inversus totalis: Feasibility and review of literature. Int J Surg Case Rep 2013;4:711-5.
McKay D, Blake G. Laparoscopic cholecystectomy in situs
inversus totalis: A case report. BMC Surg 2005;5:5.
Oms LM, Badia JM. Laparoscopic cholecystectomy in situs
inversus totalis: The importance of being left-handed. Surg Endosc 2003;17:1859-61.
Jesudason SR, Vyas FL, Jesudason MR, Govil S, Muthusami JC. Laparoscopic cholecystectomy in a patient with situs inversus. Indian J Gastroenterol 2004;23:79-80.
Arif SH. Laparoscopic cholecystectomy in situs
inversus totalis. World J Laparosc Surg 2010;3:63-5.
Lipschutz JH, Canal DF, Hawes RH, Ruffolo TA, Besold MA, Lehman GA. Laparoscopic cholecystectomy and ERCP with sphincterotomy in an elderly patient with situs inversus. Am J Gastroenterol 1992;87:218-20.
Goh P, Tekant Y, Shang NS, Ngoi SS. Laparoscopic cholecystectomy in a patient with empyema of the gallbladder and situs inversus. Endoscopy 1992;24:799-800.
Drover JW, Nguyen KT, Pace RF. Laparoscopic cholecystectomy in a patient with situs inversus viscerum: A case report. Can J Surg 1992;35:65-6.
Huang SM, Chau GY, Lui WY. Laparoscopic cholecystectomy for cholelithiasis in a patient with situs inversus totalis. Endoscopy 1992;24:802-3.
McDermott JP, Caushaj PF. ERCP and laparoscopic cholecystectomy for cholangitis in a 66-year-old male with situs inversus. Surg Endosc 1994;8:1227-9.
Elhomsy G, Matta W, Varaei K, Garcet L, Rahmani M. The millepede and the surgeon. Apropos of laparoscopic cholecystectomy in a case of situs inversus or automatic gesture constricted by reason. J Chir (Paris) 1996;133:43.
Malatani TS. Laparoscopic cholecystectomy in situs
inversus totalis: A case report and a review of the literature. Ann Saudi Med 1996;16:458-9.
D'Agata A, Boncompagni G. Video laparoscopic cholecystectomy in situ
viscerum inversus totalis. Minerva Chir 1997;52:271-5.
Habib Z, Shanafey S, Arvidsson S. Laparoscopic cholecystectomy in situs
viscerum inversus totalis. Ann Saudi Med 1998;18:247-8.
Demetriades H, Botsios D, Dervenis C, Evagelou J, Agelopoulos S, Dadoukis J. Laparoscopic cholecystectomy in two patients with symptomatic cholelithiasis and situs inversus totalis. Dig Surg 1999;16:519-21.
Djohan RS, Rodriguez HE, Wiesman IM, Unti JA, Podbielski FJ. Laparoscopic cholecystectomy and appendectomy in situs
inversus totalis. JSLS 2000;4:251-4.
Wong J, Tang CN, Chau CH, Luk YW, Li MK. Laparoscopic cholecystectomy and exploration of common bile duct in a patient with situs inversus. Surg Endosc 2001;15:218.
Donthi R, Thomas DJ, Sanders D, Schmidt SP. Report of laparoscopic cholecystectomy in two patients with left-sided gallbladders. JSLS 2001;5:53-6.
Nursal TZ, Baykal A, Iret D, Aran O. Laparoscopic cholecystectomy in a patient with situs inversus totalis. J Laparoendosc Adv Surg Tech A 2001;11:239-41.
Singh K, Dhir A. Laparoscopic cholecystectomy in situs
inversus totalis: A case report. Surg Technol Int 2002;10: 107-8.
Trongé A, Monestés J, Trongé C, Genna A. Abdominal situs inversus: Report of case. Acta Gastroenterol Latinoam 2002;32:43-5.
Polychronidis A, Karayiannakis A, Botaitis S, Perente S, Simopoulos C. Laparoscopic cholecystectomy in a patient with situs inversus totalis and previous abdominal surgery. Surg Endosc 2002;16:1110.
Kang SB, Han HS. Laparoscopic exploration of the common bile duct in a patient with situs inversus totalis. J Laparoendosc Adv Surg Tech A 2004;14:103-6.
Docimo G, Manzi F, Maione L, Canero A, Veneto F, Lo Schiavo F, et al.
Case report: Laparoscopic cholecystectomy in situs
viscerum inversus. Hepatogastroenterology 2004;51:958-60.
Antal A, Kovács Z, Szász K. Unusual laparoscopic surgical cases: Cholelithiasis in situs
inversus totalis, and gallbladder agenesis. Magy Seb 2004;57:81-3.
Pitiakoudis M, Tsaroucha AK, Katotomichelakis M, Polychronidis A, Simopoulos C. Laparoscopic cholecystectomy in a patient with situs inversus using ultrasonically activated coagulating scissors. Report of a case and review of the literature. Acta Chir Belg 2005;105:114-7.
Kamitani S, Tsutamoto Y, Hanasawa K, Tani T. Laparoscopic cholecystectomy in situs
inversus totalis with "inferior" cystic artery: A case report. World J Gastroenterol 2005;11:5232-4.
Puglisi F, Troilo VL, De Fazio M, Capuano P, Lograno G, Catalano G, et al.
Cholecystectomy in situs
viscerum inversus totalis. Does laparoscopy increase the pitalls? Chir Ital 2006;58:179-83.
Aydin U, Unalp O, Yazici P, Gurcu B, Sozbilen M, Coker A. Laparoscopic cholecystectomy in a patient with situs inversus totalis. World J Gastroenterol 2006;12:7717-9.
Kirshtein B, Lantsberg S, Mizrahi S, Lantsberg L. Laparoscopic cholecystectomy for acute cholecystitis in patient with situs viscerum inversus. Surg Laparosc Endosc Percutan Tech 2006;16:169-71.
Kumar S, Fusai G. Laparoscopic cholecystectomy in situs
inversus totalis with left-sided gall bladder. Ann R Coll Surg Engl 2007;89:W16-8.
Fernandes MN, Neiva IN, de Assis Camacho F, Meguins LC, Fernandes MN, Meguins EM. Three-port laparoscopic cholecystectomy in a brazilian Amazon woman with situs inversus totalis: Surgical approach. Case Rep Gastroenterol 2008;2:170-4.
Hamdi J, Abu Hamdan O. Laparoscopic cholecystectomy in situs
inversus totalis. Saudi J Gastroenterol 2008;14:31-2.
Pavlidis TE, Psarras K, Triantafyllou A, Marakis GN, Sakantamis AK. Laparoscopic cholecystectomy for severe acute cholecystitis in a patient with situs inversus totalis and posterior cystic artery. Diagn Ther Endosc 2008;2008:465272.
Ghosh N, Roy A, Bhatacharya S, Mukherjee S, Saha M. Lap Chole in SIT, a modified approach. Internet J Surg 2008;19:2.
Taskin M, Zengin K, Ozben V. Concomitant laparoscopic adjustable gastric banding and laparoscopic cholecystectomy in a super-obese patient with situs inversus totalis who previously underwent intragastric balloon placement. Obes Surg 2009;19:1724-6.
Masood R, Samiullah, Chaudhary IA, Taimur. Laparoscopic cholecystectomy for left sided gall bladder: An unusual case. J Ayub Med Coll Abbottabad 2009;21:162-3.
Pereira-Graterol F, Siso-Calderón L. Technical considerations during laparoscopic cholecystectomy in a patient with situs inversus totalis. Cir Cir 2009;77:145-8.
Romano GG, Grande G, Romano F, Di Luna G, Musto LA, Saldutti L. Laparoscopic cholecystectomy in situs
viscerum inversus totalis: Technical note. G Chir 2009; 30:369-73.
Eisenberg D. Cholecystectomy in situs
inversus totalis: A laparoscopic approach. Int Med Case Rep J 2009;2:27-9.
Pataki I, Soultan TG, Chanis W. Laparoscopic cholecystectomy in totalis situs inversus for cholecystitis. Magy Seb 2010;63:23-5.
Hall TC, Barandiaran J, Perry EP. Laparoscopic cholecystectomy in situs
inversus totalis: Is it safe? Ann R Coll Surg Engl 2010;92:W30-2.
González Valverde FM, Gómez Ramos MJ, Méndez Martínez M, Pérez Montesinos JM, Tamayo Rodríguez ME, Ruiz Marín M, et al
. Laparoscopic cholecystectomy in a patient with situs inversus totalis. Acta Gastroenterol Latinoam 2010;40:264-7.
Sandu C, Toma M. Laparoscopic cholecystectomy in a patient with situs inversus totalis. Chirurgia (Bucur) 2010;105:705-7.
Borgaonkar VD, Deshpande SS, Kulkarni VV. Laparoscopic cholecystectomy and appendicectomy in situs
inversus totalis: A case report and review of literature. J Minim Access Surg 2011;7:242-5.
Han HJ, Choi SB, Kim CY, Kim WB, Song TJ, Choi SY. Single-incision multiport laparoscopic cholecystectomy for a patient with situs inversus totalis: Report of a case. Surg Today 2011;41:877-80.
Uludag M, Yetkin G, Kartal A. Single-incision laparoscopic cholecystectomy in situs
inversus totalis. JSLS 2011; 15:239-43.
Ozsoy M, Haskaraca MF, Terzioglu A. Single incision laparoscopic cholecystectomy (SILS) for a patient with situs inversus totalis. BMJ Case Rep 2011;doi:10.1136/bcr.08.2011.4581.
Pahwa HS, Kumar A, Srivastava R. Laparoscopic cholecystectomy in situs
inversus: Points of technique. BMJ Case Rep 2012;doi:10.1136/bcr-2012-006170.
de Campos Martins MV, Pantaleão Falcão JL, Skinovsky J, de Faria GM. Single-port cholecystectomy in a patient with situs inversus totalis presenting with cholelithiasis: A case report. J Med Case Rep 2012 3;6:96.
Evoli LP, Miglionico L, Graziosi L, Cavazzoni E, Bugiantella W, Dei Santi V, et al.
Laparoscopic cholecystectomy for a symptomatic cholelithiasis in a patient presenting situs viscerum inversus totalis. A case report. Ann Ital Chir 2012;83:63-6.
Lochman P, Hoffmann P, Kocí J. Elective laparoscopic cholecystectomy in a 75-year-old woman with situs viscerum inversus totalis. Wideochir Inne Tech Malo Inwazyjne 2012;7:216-9.
Iusco DR, Sacco S, Ismail I, Bonomi S, Virzì S. Three-trocar laparoscopic cholecystectomy in patient with situs viscerum inversus totalis: Case report and review of the literature. G Chir 2012;33:10-3.
Demiryilmaz I, Yilmaz I, Albayrak Y, Peker K, Sahin A, Sekban N. Laparoscopic cholecystectomy in patients with situs inversus totalis: Literature review of two patients. Iran Red Crescent Med J 2012;14:826-8.
Arya SV, Das A, Singh S, Kalwaniya DS, Sharma A, Thukral BB. Technical difficulties and its remedies in laparoscopic cholecystectomy in situs
inversus totalis: A rare case report. Int J Surg Case Rep 2013;4:727-30.
Ali MS, Attash SM. Laparoscopic cholecystectomy in a patient with situs inversus totalis: Case report with review of literature. BMJ Case Rep 2013;doi:10.1136/bcr-2013-201231.
Raghuveer MN, Mahesh Shetty S, Kumar BB. Laparoscopic cholecystectomy in situs
inversus totalis. J Clin Diagn Res 2014;8:ND03-5.
Moirangthem GS, Chowdhary AS, Charaborty G, Lokendra K, Prabhu T. Laparoscopic cholecystectomy in a patient of situs inversus at regional institute of medical sciences (RIMS). J Med Soc 2014;28:60-2.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]