INTRODUCTION:
Situs Inversus is a rare congenital recessive autosomal malformation, which is characterized by the viscera’s transposition which may be thoracic, abdominal or both (1, 2). Worldwide prevalence of this anomaly varies from 0.04% to 0.30% (3). Situs inversus is divided into two types: situs inversus partialis, which involves the thoracic organs (dextrocardia) or abdominal viscera, and situs inversus totalis, which involves both the thoracic organs and abdominal viscera (4).
Though situs inversus on its own is not pathological, it may be associated with cardiorespiratory, hepatopancreaticobiliary, gastrointestinal, neurological, orthopedic and urological anomalies, some of which may be life-threatening (2). Surgeons must be aware of this anatomy to diagnose and surgically treat patients with situs inversus who develop gallbladder disease (3, 4). In 1991, Campos and Sipes [5] reported the first successful laparoscopic cholecystectomy in a patient with situs inversus with a symptomatic gallstone. Several case reports and laparoscopic cholecystectomy techniques were subsequently published. We report our first laparoscopic cholecystectomy in a female patient with symptomatic cholelithiasis in a setting of situs inversus totalis. CASE REPORT A 57-year-old woman presented to the surgical emergency with pain left upper abdomen and epigastrium radiating to back. Clinical examination revealed tenderness in left hypochondrium and epigastrium. On chest auscultation apex beat was found on right side. Imaging by an ultrasound scan showed abdominal situs inversus with gall stones in a left-sided gall bladder. A pre-operative chest X-ray showed dextrocardia consistent with situs inversus. Serum amylase and lipase were raised and patient was diagnosed as case of Acute Biliary pancreatitis. CT scan abdomen with oral and intravenous contrast showed situs inversus with acute pancreatitis having CT severity index of 4. Figure 1: chest X-Ray showing Figure 2: CT scan abdomen showing Cardiac shadow on right side liver on left side and spleen on right Figure 3: CT scan abdomen showing Swollen pancreas (red arrow) Figure 4: laparoscopic ports for Situs inversus Umbilical port red arrow and left hypochondrial ports black arrows Patient was initially managed conservatively and laparoscopic surgery was planned. The approach in the operating room required modification. The surgeon and the assistant were positioned on the right side of the patient and the scrub nurse on the left. A head-end-up and left-side-up positioning of the patient was adopted to optimize views of the gall bladder and the Calot’s triangle. A 4-port technique was used – an umbilical (10 mm), a medial epigastric (10 mm) and two lateral subcostal (5 mm) ports . Initial inspection confirmed a left-sided liver and gall bladder. There was a total situs inversus with the spleen on the right side, the greater curve of the stomach to the right and the caecum to the left. The …show more content…
In 1991, Campos and Sipes reported the first successful laparoscopic cholecystectomy in a patient with situs inversus with a symptomatic gallstone (5). In literature there are fifty cases of laparoscopic cholecystectomy in patients with situs inversus totalis are reported. To deal with this eccentric anatomy of gall bladder, it is required to highlight the importance of a new pre-operatory planning, which involves a repositioning of the surgical team and the trocars in the left side of the abdomen. The standard four port technique was used in our case as recommended and reported in other studies (3.4,5,6). In order to optimize the surgical procedure in our operation, the operative equipment, surgeon’s position, and port placement were prepared as a “mirror image” to the routine laparoscopic cholecystectomy. In fact, the most crucial step of the operation is to achieve the critical level for safety of Calot,s Triangle (9). In our case the dissection of the cholecystic pedicle in left sided gall bladder was not time-consuming, but was uncomfortable and difficult. The operating surgeon was right handed and the dissection of Calot,s triangle and cholecystic pedicle was done by epigastric port and left subcostal port. Lochman et al. (6) and Arya et al. (10) performed the operation with an assistant surgeon grasping the infundibulum. The principal surgeon performed the dissection with only his dominant right hand via the epigastric port. Another technique to improve the operative ergonomics is to place the patient in lithotomy position and operating surgeon stands between patient legs with dissection of Calot,s triangle done with right subcostal port. Patle et al (11) performed five cases via
Situs Inversus is a rare congenital recessive autosomal malformation, which is characterized by the viscera’s transposition which may be thoracic, abdominal or both (1, 2). Worldwide prevalence of this anomaly varies from 0.04% to 0.30% (3). Situs inversus is divided into two types: situs inversus partialis, which involves the thoracic organs (dextrocardia) or abdominal viscera, and situs inversus totalis, which involves both the thoracic organs and abdominal viscera (4).
Though situs inversus on its own is not pathological, it may be associated with cardiorespiratory, hepatopancreaticobiliary, gastrointestinal, neurological, orthopedic and urological anomalies, some of which may be life-threatening (2). Surgeons must be aware of this anatomy to diagnose and surgically treat patients with situs inversus who develop gallbladder disease (3, 4). In 1991, Campos and Sipes [5] reported the first successful laparoscopic cholecystectomy in a patient with situs inversus with a symptomatic gallstone. Several case reports and laparoscopic cholecystectomy techniques were subsequently published. We report our first laparoscopic cholecystectomy in a female patient with symptomatic cholelithiasis in a setting of situs inversus totalis. CASE REPORT A 57-year-old woman presented to the surgical emergency with pain left upper abdomen and epigastrium radiating to back. Clinical examination revealed tenderness in left hypochondrium and epigastrium. On chest auscultation apex beat was found on right side. Imaging by an ultrasound scan showed abdominal situs inversus with gall stones in a left-sided gall bladder. A pre-operative chest X-ray showed dextrocardia consistent with situs inversus. Serum amylase and lipase were raised and patient was diagnosed as case of Acute Biliary pancreatitis. CT scan abdomen with oral and intravenous contrast showed situs inversus with acute pancreatitis having CT severity index of 4. Figure 1: chest X-Ray showing Figure 2: CT scan abdomen showing Cardiac shadow on right side liver on left side and spleen on right Figure 3: CT scan abdomen showing Swollen pancreas (red arrow) Figure 4: laparoscopic ports for Situs inversus Umbilical port red arrow and left hypochondrial ports black arrows Patient was initially managed conservatively and laparoscopic surgery was planned. The approach in the operating room required modification. The surgeon and the assistant were positioned on the right side of the patient and the scrub nurse on the left. A head-end-up and left-side-up positioning of the patient was adopted to optimize views of the gall bladder and the Calot’s triangle. A 4-port technique was used – an umbilical (10 mm), a medial epigastric (10 mm) and two lateral subcostal (5 mm) ports . Initial inspection confirmed a left-sided liver and gall bladder. There was a total situs inversus with the spleen on the right side, the greater curve of the stomach to the right and the caecum to the left. The …show more content…
In 1991, Campos and Sipes reported the first successful laparoscopic cholecystectomy in a patient with situs inversus with a symptomatic gallstone (5). In literature there are fifty cases of laparoscopic cholecystectomy in patients with situs inversus totalis are reported. To deal with this eccentric anatomy of gall bladder, it is required to highlight the importance of a new pre-operatory planning, which involves a repositioning of the surgical team and the trocars in the left side of the abdomen. The standard four port technique was used in our case as recommended and reported in other studies (3.4,5,6). In order to optimize the surgical procedure in our operation, the operative equipment, surgeon’s position, and port placement were prepared as a “mirror image” to the routine laparoscopic cholecystectomy. In fact, the most crucial step of the operation is to achieve the critical level for safety of Calot,s Triangle (9). In our case the dissection of the cholecystic pedicle in left sided gall bladder was not time-consuming, but was uncomfortable and difficult. The operating surgeon was right handed and the dissection of Calot,s triangle and cholecystic pedicle was done by epigastric port and left subcostal port. Lochman et al. (6) and Arya et al. (10) performed the operation with an assistant surgeon grasping the infundibulum. The principal surgeon performed the dissection with only his dominant right hand via the epigastric port. Another technique to improve the operative ergonomics is to place the patient in lithotomy position and operating surgeon stands between patient legs with dissection of Calot,s triangle done with right subcostal port. Patle et al (11) performed five cases via