|Year : 2014 | Volume
| Issue : 1 | Page : 60-62
Laparoscopic cholecystectomy in a patient of Situs Inversus at Regional Institute of Medical Sciences (RIMS)
GS Moirangthem, Ch Arunkumar Singh, Goutam Chakraborty, Ksh Lokendra, T Prabhu
Department of Surgery, Surgical Gastroenterology and Minimal Access Surgery Unit, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||24-Jun-2014|
Dr. Goutam Chakraborty
Department of Surgery, Surgical Gastroenterology and Minimal Access Surgery Unit, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
Situs inversus is also known as situs transversus or oppositus and is a congenital condition. In this condition, the major visceral organs are observed to be reversed or mirrored from their normal position. Symptomatic cholelithiasis in a patient of situs inversus can give rise to diagnostic dilemma and calls for modification of the surgeon's operative approach. Owing to the rarity of the condition, here, we report a case of laparoscopic cholecystectomy in a patient of situs inversus at Regional Institute of Medical Sciences (RIMS). Though operative time was slightly prolonged and there were minor orientation difficulties, intra-operative and post-operative periods were uneventful and there is no report of complication till date.
Keywords: Laparoscopic cholecystectomy, Kartagener′s syndrome, Situs inversus
|How to cite this article:|
Moirangthem G S, Singh C, Chakraborty 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
|How to cite this URL:|
Moirangthem G S, Singh C, Chakraborty G, Lokendra K, Prabhu T. Laparoscopic cholecystectomy in a patient of Situs Inversus at Regional Institute of Medical Sciences (RIMS). J Med Soc [serial online] 2014 [cited 2020 Oct 20];28:60-2. Available from: https://www.jmedsoc.org/text.asp?2014/28/1/60/135240
| Introduction|| |
Situs inversus totalis is a very uncommon entity. It was first reported by Fabricius in 1600.  It is an autosomal recessive inherited transposition of thoracic and abdominal viscera. Although it is not pathological in itself, it may be associated with some anomalies, predominantly cardiac ones, that can potentially be life-threatening. , There is no predisposition to cholelithiasis in situs inversus patients however.  If the heart is swapped to right side of the thorax, it is called situs inversus with dextrocardia or situs inversus totalis (incidence: 1 per 5000-20,000 live births , ). If the heart remains in the normal left side of the thorax, it is known as situs inversus with levocardia or situs inversus partialis.
Situs inversus occurs more commonly with dextrocardia. A 3-5% incidence of congenital heart disease is observed in situs inversus with dextrocardia and usually transposition of great vessels and out of these patients, 80% have right-sided aortic arch. Situs inversus with levocardia is rare and it is almost always associated with congenital heart disease. In 20% of this congenital anomalous condition, situs inversus can be a component of Kartagener's syndrome consisting of bronchiectasis, sinusitis, and situs inversus.
The recognition of situs inversus is important for preventing surgical mishaps that result from the failure to recognise reversed anatomy. For example, in a patient with situs inversus, cholecystitis typically causes left upper quadrant pain and appendicitis causes left lower quadrant pain.
A trauma patient with evidence of external trauma over the right ninth to eleventh ribs is at risk of splenic injury. Hence, thorough clinical and radiological assessment of the patient and prior operative set-up in accordance with the alteration in the usual orientation are of supreme importance. In the published literature, there have been only about 40 reports of open cholecystectomy in pre-laparoscopic era and 20 reports of laparoscopic cholecystectomy in patients with situs inversus. , Here, we report a case of laparoscopic cholecystectomy in a patient of situs inversus totalis at Regional Institute Of Medical Sciences (RIMS), Imphal.
| Case Report|| |
A 50-year-old woman presented with pain left upper quadrant of abdomen off and on radiating to left scapular region and aggravated by fatty food. There was no jaundice, pyrexia, or pruritis. No history of systematic comorbidity. Clinical examination revealed apex beat in right 5 th intercostal space in the midclavicular line. Routine blood and urine examination were within normal limits. Chest X-ray (posteroanterior, PA, view) showed dextrocardia consistent with situs inversus [Figure 1]. Electrocardiogram showed right axis deviation in R-waves and P-waves, positively deflected QRS complex in a ventriculophasic response (VR) and poor R-wave progression [Figure 2]. An ultrasonography of upper abdomen revealed the gall bladder (GB) containing stones in the left upper quadrant. Spleen was visualized in the right upper quadrant. There was no evidence of common bile duct or intra-hepatic duct dilatation. The diagnosis of cholelithiasis was thus made. A magnetic resonance imaging (MRI) was done which re-confirmed the diagnosis [Figure 3].
|Figure 1 : Chest X-ray (PA view) showing dextrocardia. PA: Posteroanterior|
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|Figure 2 : ECG findings consistent with dextrocardia. ECG: Electrocardiography|
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|Figure 3 : MRI abdomen showing reversed orientation of visceras. MRI: Magnetic imaging resonance|
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In order to conduct laparoscopic cholecystectomy, all the equipments including diathermy, CO 2 insufflator, and monitor were positioned in the mirror image of their normal position. The surgical team also changed sides with the primary surgeon and the 2 nd assistant on the patient's right and the 1 st assistant on left. The pneumoperitoneum was induced using veress needle through sub-umbilical incision and pressure was built up till 14 mm of Hg. Four port sites were made, two 10 mm each (through the subumbilical incision and another in subxiphoid position) and two 5 mm each (in the midclavicular line in left hypochondrium and anterior axillary line on the left in the line of umbilicus). On initial inspection of the intra-abdominal cavity, the entirety of the abdominal visceras were indeed reversed. The chief surgeon being right handed, to carry out the surgery in an ergonomic fashion was a concern. So that the surgeon need not cross his hands, dissection of the calot's triangle and clipping of cystic artery and cystic duct was performed by right hand through the epigastric port. Traction on the Hartmann's pouch was provided by left hand of the surgeon through the port on midclavicular line. After dividing the cystic artery and duct, GB was separated from the liver bed by harmonic scalpel, controlling minor oozing by the bipolar cautery. GB was extracted through the epigastric port. To be on the safer side, a tube drain (Ryle's tube no.16) was kept in Morrison's pouch. Port sites were closed with absorbable suture. Our operating time was 75 minutes. Intra-operation and post-operation periods were uneventful. She was discharged on POD 2 and followed up in outpatient department (OPD) after 2 weeks when she was found to be recovering well and there is no report of post-operative complications till date.
| Discussion|| |
Campos and Sipes conducted the first laparoscopic cholecystectomy in a patient of situs inversus in 1991.  Han et al. published the first case of single-incision multiport laparoscopic cholecystectomy in a situs inversus patient.  Situs inversus does not predispose one to gallstone but leads to diagnostic confusion, and hence, a high index of suspicion is needed to avoid mishaps in a patient of situs inversus presenting with acute abdomen.
An apical beat in the right 5 th intercostal space, left sided liver dullness, and the right testis hanging lower than the left occassionally suggest situs inversus. Abdominal ultrasonography (USG), computed tomography (CT), and MRI may re-establish the diagnosis. The anatomical variation and mainly the contralateral disposition of the biliary tree demand an accurate dissection and exposure of the biliary structures to avoid iatrogenic injuries. The position of the surgeon and the orientation of the set-up has to be reversed. Technically, left-handed surgeons find it easier to perform laparoscopic cholecystectomy in situs inversus.  The dissection of the biliary tree can be carried out with either the right or left hand. But, for right-handed surgeons using the non-dominant left hand may be troublesome. This is most apparent during clip application when both precision and strength are required. The skeletonization of the structure of calot's triangle is time-consuming. Hence, modifications like surgeon standing in between the abducted legs of the patient (Lloyd-Davis position)  or allowing the first assistant to retract Hartmann's pouch while the primary surgeon dissects calot's triangle using his right hand via the epigastric port are often more logical. 
Apart from mirror image transposition, patients with situs inversus totalis usually do not have extrahepatic biliary, venous, and arterial anomalies. Hence, surgeon should not be apprehensive about performing Laparoscopic cholecystectomy for situs inversus on ground of unexpected associated biliary tract anomalies. However, in patients with situs inversus partialis, there is an increased possibility of associated biliary tract and vascular anomalies. Such patients may need intra-operative cholangiography and have low threshold for conversion to open surgery. Whereas, others still feel it is safer to perform laparoscopic cholecystectomy in such patients also. 
| Conclusion|| |
A laparoscopic cholecystectomy for cholelithiasis on a 50-year-old female patient having a rare congenital condition of situs inversus totalis is hereby reported. In view of the reversed and mirrored position of the abdominal visceras, it is no doubt technically demanding to perform laparoscopic cholecystectomy. It requires mental adaptability and manual dexterity to cope with any evolving difficult or potentially dangerous intra-operative situation.
Based on this case report and review of literature, though limited in view of its rarity, we would like to draw a conclusion that laparoscopic cholecystectomy in situs inversus totalis is feasible and can be recommended as a procedure of choice if performed by an expert hand with extra care and without compromising on operating time.
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[Figure 1], [Figure 2], [Figure 3]