Laparoscopic cholecystectomy in situs inversus-our experience of 6 cases

Laparoscopic Cholecystectomy in Situs Inversus Totalis: A Case Report

Situs inversus totalis is a rare condition characterized by the mirror image of the normal abdominal and thoracic viscera. Since the gallbladder is located in the left upper quadrant in this subset of patients, the diagnosis of symptomatic cholelithiasis poses a difficulty. Similarly, laparoscopic cholecystectomy in these patients is more demanding and presents technical challenges, especially for right-handed surgeons. Herein, we report a case of a 30-year-old female who was a known case of situs inversus totalis and was diagnosed with symptomatic cholelithiasis and subsequently underwent laparoscopic cholecystectomy with an uneventful post-operative period. The challenge while performing laparoscopic cholecystectomy in patients with situs inversus totalis calls for appropriate perioperative preparation and necessary modifications in the operative setup for the safe and successful operation of the patient, which is discussed in this report.

Two Surgeons' Technique for Laparoscopic Cholecystectomy in Situs Inversus for a Right-Handed Surgeon: Technical and Ergonomic Considerations

Laparoscopic cholecystectomy can be technically challenging in patients with situs inversus totalis. A middle-aged gentleman presented with pain in the left upper abdomen. His cardiac workup showed dextrocardia, and ultrasonography showed a gall bladder on the left side. He was diagnosed with acute cholecystitis and was planned for laparoscopic cholecystectomy. We used the four-port technique, where anterior dissection was carried out by the dominant right hand of the primary surgeon, and the infundibulum was retracted by the first assistant from the mid-clavicular port. The first assistant carried out the posterior dissection through a midclavicular port, whereas the primary surgeon did a retraction. To conclude, this technique done by two surgeons decreases the ergonomic difficulty faced by right-handed surgeons while performing laparoscopic cholecystectomy.

Laparoscopic common bile duct exploration to treat choledocholithiasis in situs inversus patients: A technical review

Situs inversus (SI) is a rare congenital condition characterized by a mirror-image transposition of the major visceral organs. Since the 1990s, more than one hundred SI patients have been reported to have successfully undergone laparoscopic cholecystectomy. In these cases, the major problem is to overcome is the left-right condition for right-handed surgeons. Laparoscopic common bile duct exploration (LCBDE), an alternative to treat patients with bile duct stones, has shown equivalent efficacy and is less likely to cause pancreatitis than endoscopic retrograde cholangiopancreatography. Recent updated meta-analyses revealed that a shorter postoperative hospital stay, fewer procedural interventions, cost-effectiveness, a higher stone clearance rate, and fewer perioperative complications are additional advantages of LCBDE. However, the technique is technically demanding, even for skilled laparoscopic surgeons. Conducting LCBDE in patients with difficult situations, such as SI, is more complex than usual. We herein review published SI patients with choledocholithiasis treated by LCBDE, including our own experience, and this paper focuses on the technical aspects.

Look beyond the Mirror: Laparoscopic Cholecystectomy in Situs Inversus Totalis-A Systematic Review and Meta-Analysis (and Report of New Technique)

BACKGROUND

Laparoscopic cholecystectomy in situs inversus totalis (SIT) is a technically and physically demanding procedure for surgeons and there is still a lack of consensus regarding the best technical approach in such cases. We conducted a systematic review and meta-analysis to evaluate port placement, the dominant hand of the surgeon, preoperative imaging, morbidity, and mortality.

METHODS

We searched MEDLINE, SCOPUS, Web of Science, and the Cochrane Library for studies of patients with SIT that underwent laparoscopic cholecystectomy. Of 387 identified records, 101 met our inclusion criteria, all of them case reports or case series of maximum of 6 patients.

RESULTS

Out of the 121 patients included in the analysis, 94 were operated on using a "mirrored American" technique, 12 using the "Mirrored French", 9 employed single-port techniques, and 6 described novel port placements. Even though most surgeries were conducted by a right-handed surgeon (93 cases), surgeries performed by the seven left-handed surgeons yielded shorter intervention times (p = 0.024). Preoperative imaging (CT, MRI, MRCP, ERCP) also correlated with a lower duration of surgery (p = 0.038. Length of stay was associated with the type of disease, but not with other studied endpoints. Morbidity was less than 1%, and conversion rates and mortality were nil.

CONCLUSIONS

Cholecystectomy in SIT is a safe but challenging procedure and surgeons should prepare in advance for the unfamiliar aspects of completing such a task. While preoperative imaging and a left-handed surgeon are beneficial in terms of surgery length, when these are not available surgeons should focus on achieving the most comfortable setting based on their experience and tailor their approach to the patient at hand. Further studies are needed in order to properly describe and evaluate intraoperative findings as well as surgeon-dependent factors that could improve future recommendations.

Laparoscopic cholecystectomy in situs inversus totalis: Case report with review of techniques

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SIT is a rare congenital anatomy with mirror image transposition of the viscera.

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The underlying anatomical variation poses a challenge in the diagnosis and management of cholelithiasis In patient with SIT.

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Laparoscopic cholecystectomy can be safely performed in these cases.

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It is considered technically challenging procedure and often requires alteration in the technique compared to the conventional laparoscopic cholecystectomy.

Introduction

Situs inversus totalis (SIT) is a congenital disorder in which the visceral organs are mirrored from their normal anatomical position. Diagnosis and management of cholelithiasis in patient with SIT poses a challenge due to the underlying anatomical variation.

Presentation of case

We report a case of a 40-year-old male patient who presented with an intermittent history of epigastric and left upper quadrant pain for one month. Clinical assessment and radiological investigations confirmed the presence of cholelithiasis with evidence of SIT. The patient underwent elective laparoscopic cholecystectomy with no complication and he had an uneventful recovery. Various intraoperative modification has been made to overcome the technical difficulties encountered due to the underlying anatomical variation.

Discussion

Since the first successful laparoscopic cholecystectomy in patient with SIT performed in 1991, 85 cases have been reporsted in the literature. Surgeons managed to overcome the technical difficulties by adopting various modification in the techniques compared to the conventional laparoscopic cholecystectomy.

Conclusion

The anatomical variation in SIT can influence the localization of symptoms in patient with cholelithiasis leading to a delay in diagnosis and management. Laparoscopic cholecystectomy can be safely performed in these cases. However, it is considered technically challenging procedure and often requires alteration in the technique.

Our experience with surgery in situs inversus: Open peptic perforation repair and laparoscopic cholecystectomy in 1 patient and 3 patients respectively

INTRODUCTION

Situs inversus is a rare autosomal recessive condition associated with complete transposition of abdominal+/- thoracic organs. Surgical diagnosis and surgical procedures in patients with situs inversus is tricky because of the mirror image anatomy of intra-abdominal organs.

MATERIALS AND METHODS

A retrospective analysis of 2152 and 1497 patients who underwent laparoscopic cholecystectomy and open peptic perforation repair respectively from June 2014-June 2016 was done. 1 patient and 3 patients with situs inversus underwent open peptic perforation repair and laparoscopic cholecystectomy respectively. A 10mm left para-median port 5cm caudally from xiphoid was used for grasping the infundibulum. Two 5mm ports placed 10cm caudally from costal margin in the mid-clavicular and anterior axillary line were used for dissecting and retracting fundus respectively. A 10mm supra-umbilical camera port was used.

RESULTS

A 40year male with situs inversus totalis underwent open peptic perforation repair. Laparoscopic cholecystectomy was done in 3 female patients with situs inversus aged 33-46year (mean 41year). Mean operative time for laparoscopic cholecystectomy was 59min (39-93). There were no intraoperative or post-operative complications. Histopathology revealed chronic inflammation in peptic perforation and cholecystitis.

CONCLUSION

Perforation peritonitis in situs inversus can cause diagnostic confusion with free gas under the left hemi diaphragm. Laparoscopic cholecystectomy in situs inversus is ergonomically inconvenient and technically difficult for right handed surgeons. We describe an ergonomically convenient port placement for right handed surgeons in situs inversus.

Simplified technique of laparoscopic cholecystectomy in a patient with situs inversus: a case report and review of techniques

BACKGROUND

Situs inversus is a rare and silent autosomal recessive disorder occurring in 1:5,000 to 1:20,000 individuals. Laparoscopic cholecystectomy, a standard treatment for gallbladder disease in the general population, is very challenging in patients with situs inversus, especially for right-handed surgeons. We herein report a case involving our modified laparoscopic cholecystectomy technique for right-handed surgeons in a Thai patient with situs inversus who developed a symptomatic gallstone. We also include a short review of the literature.

CASE PRESENTATION

A 39-year-old female patient with dextrocardia presented with a 5-month history of episodic biliary colic. Abdominal ultrasonography revealed a left-sided gallbladder with gallstones. We performed laparoscopic cholecystectomy with our modified technique including port relocation. The operation went well, and our patient recovered satisfactorily.

CONCLUSION

Laparoscopic cholecystectomy in patients with a left-sided gallbladder is not often confidently performed by right-handed surgeons. However, some modifications of "mirror image" ports focused on the more ergonomic port position are the keys to successful completion of this operation. The patient will thus still obtain benefits from this standard minimally invasive technique.

Single-port laparoscopic cholecystectomy in situs inversus totalis using the E.K. glove port

Laparoscopic cholecystectomy has become the standard treatment for symptomatic cholelithiasis in patients with situs inversus totalis (SIT). 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 post-operative pain and ensures virtually a “scar less” surgery. We report a case of successful single-port laparoscopic cholecystectomy for a patient with SIT, and describe its technical advantages and review of literature.

Technical difficulties and its remedies in laparoscopic cholecystectomy in situs inversus totalis: A rare case report

INTRODUCTION

Laparoscopic cholecystectomy is considered to be the gold standard surgical procedure for cholelithiasis and is one of the commonest surgical procedures in the world today. However, in rare cases of previously undiagnosed situs inversus totalis (with dextrocardia), the presentation of the cholecystitis, its diagnosis and the operative procedure can pose problems. We present here one such case and discuss how the diagnosis was made and difficulties encountered during surgery and how they were coped with.

PRESENTATION OF CASE

A 35 year old female presented with left hypochondrium pain and dyspepsia, for 2 years. A diagnosis of cholelithiasis with situs inversus was confirmed after thorough clinical examination, abdominal and chest X-rays and ultrasonography of the abdomen. Laparoscopic cholecystectomy, which is the standard treatment, was performed with numerous modifications in the positioning of the monitor, insufflator, ports and the position of the members of the surgical team and the laparoscopic instruments. The patient had an uneventful recovery.

DISCUSSION

Situs inversus totalis is itself a rare condition and when associated with cholelithiasis poses a challenge in the management of the condition. We must appreciate the necessity of setting up the operating theatre, the positioning of the ports, the surgical team and the instruments.

CONCLUSION

Therefore, it becomes important for the right handed surgeons to modify their techniques and establish a proper hand eye coordination to adapt to the mirror image anatomy of the Calot's triangle in a patient of situs inversus totalis.

Total laparoscopic donor nephrectomy in situs inversus totalis: a case report

Situs inversus totalis is a rare anomaly characterized by the total inversion of all abdominal and thoracic organs. For the first time, we report a case of a donor nephrectomy in a patient with situs inversus totalis, completed with a full laparoscopic approach. At the time of this writing, the donor and the recipient are doing well after 6 month's follow-up. Our experience shows that patients with situs inversus totalis may be eligible candidates for laparoscopic donor nephrectomy, provided that detailed preoperative imaging studies as well as precise preoperative planning are performed before the transplant.