Elective laparoscopic cholecystectomy in a 75-year-old woman with situs viscerum inversus totalis

Abstract

Situs viscerum inversus totalis is a rare disorder presenting with complete transposition of thoracic and abdominal viscera. It is associated with certain organ anomalies, but it is not a predisposing factor to cholecystolithiasis. To date, fewer than 100 cholecystectomies in patients with situs inversus have been published worldwide. We report a case of a 75-year-old woman referred to our hospital with abdominal pain in the left hypochondrium. Situs inversus totalis and acute calculous cholecystitis were diagnosed and successfully conservatively treated with antibiotics. The patient underwent elective laparoscopic cholecystectomy 3 months later. The procedure and postoperative course were uneventful and the patient recovered well. The clinical presentation of these patients with cholecystolithiasis may be confusing and vague and the correct diagnosis delayed. Laparoscopic cholecystectomy is the gold standard in the treatment even though the operation requires some modifications in operating theatre arrangement and position of the surgical team. Most surgeons are right-handed, and to operate laparoscopically in the “mirror image” anatomical situation using mainly the left hand for dissection may be stressful, uncomfortable and more time-consuming. Some recommendations to overcome this issue have been published. In conclusion, the above-mentioned anomaly may cause some risk and delay of the exact diagnosis, but it is not dangerous in itself. Laparoscopic cholecystectomy is a safe procedure, even in the case of acute cholecystitis, if performed by an experienced laparoscopic surgeon. The most dangerous is always an incautious and too self-confident surgeon.

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

“…Phothong et al moved the position of the left midclavicular line dissecting port 5 cm caudally to make it more ergonomically friendly [7]. A few surgeons have used the right epigastric port as the dissecting port while the assistant grasped the infundibulum [20], [21].…”

Inverting the laparoscopic cholecystectomy: a case of acute biliary pancreatitis in situs inversus

“…The operative time in our case was 30 minutes which was significantly less than that reported in literature. 4,6,12,13,15 Thus, our patient presented with symptomatic gallstones exhibiting situs inversus totalis and was operated through laparoscopic cholecystectomy successfully.…”

“…These patients usually present with pain in left upper quadrant of the abdomen; however, epigastric pain is reported to be present in 30-40% of patients. 6 Approximately, 10% patients present with right hypochondrial pain. Our patient presented with left hypochondrial pain which is the classical presentation in patients with situs inversus.…”

“…The standard four port technique was used in our case as recommended and reported in other studies as well. 3,4,6,9 In order to optimize the surgical procedure, a "mirror image" to routine laparoscopic cholecystectomy was adopted. Surgeon stood on the right side of the patient, and all operative equipment and ports were placed on left side of the patient.…”

“…Lochman et al and Arya et al also adopted this technique for performing laparoscopic cholecystectomy in situs inversus patients. 6,12 In order to improve the operative ergodynamics, an alternative technique can be adopted. The patient is placed in the lithotomy position with the surgeon standing in between the patient legs and calot's triangle been dissected through right subcostal port.…”