Alternate Technique for Doing Laparoscopic Cholecystectomy in Situs Inversus *

A 45-year-old female with known situs inversus totalis presented with left-sided abdominal discomfort. Chest X-ray, abdominal ultrasonography and CT scan confirmed the diagnosis of a gallstone, as well as, situs inversus; Laparoscopic cholecystectomy was safely performed with mirror image of standard 4 ports. Callots triangle dissection was done with epigastric working port by surgeon, but gallbladder fossa dissection was done by surgical assistant from midclavicular port as main working port. Laparoscopic surgeon should be careful for view of reversed relationships and also for existence of other anomalies.


Introduction
Situs inversus is a morphological anomaly of positioning of internal viscera wherein there is a reversal of the usual "handedness" of visceral topography.The reversal may be thoracic, abdominal or both.It is estimated to occur in 1 in 5000 -20,000 births [1,2].In the published literature, there have been only about 40 reports of open cholecystectomy in the pre-laparoscopic era and 20 reports of laparoscopic cholecystectomy in patients with situs inversus [2][3][4].Although there are many reports of patients with situs inversus and cholelithiasis, there is no evidence that the incidence of cholelithiasis is greater in these patients [5].It has been reported that about a third of patients with situs inversus and symptomatic gall stones may, however, present with epigastric pain and about 10% of patients may present with right-sided pain [6].

Case Report
Our patient was a 45-year-old female patient, who had four children.Patient presented with pain left side of abdomen and was been treated with antibiotics and painkillers with no relief, after which ultrasound was done which re-vealed left sided gallbladder with stones in it.Patient had no co-morbidities or anomalies.
Chest X-ray showed dextrocardia consistent with situs inversus but there was no evidence of Bronchiectasis (Figure 1).
The surgical procedure was modified according to our comfort.The surgeon and the camera man were positioned on the right side of the patient.An assistant and the scrub nurse were positioned on the left side (Figure 4).The video monitor was placed on the head end of patient.Standard 4-port mirror image technique was used -an umbilical (10 mm), epigastric (10 mm) and two subcostal (5 mm) ports.Pneumoperitoneum was established by open technique.10 mm camera port was inserted.A head-end-up and left-side-up positioning of the patient was adopted to optimize views of the gall bladder and the Callot's triangle.The epigastric port (10 mm) was placed just to the left of the falciform ligament.This port was one of the two main operating ports and the instruments used were controlled by the right hand of the surgeon.It was used for dissection of callots triangle.The medial subcostal port was used for retraction of the Hartmann's pouch of the gall bladder initially and later for gallbladder bed dissection.The lateral subcostal port was used for fundal traction.
Diagnostic laparoscopy revealed a total situs inversus with left-sided liver and gall bladder, greater curvature and cecum.The organs on right side included spleen and the greater curve of the stomach (Figure 5).
Surgery was started with fundal retraction through lateral subcostal port, Hartmann's pouch retraction was done with medial subcostal port, and Callot's triangle dissection was done with epigastric port.Cystic artery and cystic duct were identified after dissection and clipped separately.After clipping cystic duct and cystic artery epigastric port was used as retraction port and medial subcostal port was used as dissecting port.This switching   of dissecting port facilitated easy and smooth dissection of gallbladder from the gallbladder fossa.The gall bladder bed dissection was done by the surgeon who was assisting the case and standing on left side of patient.Our total operative time was 90 minutes.

Discussion
The cause of the situs inversus is unknown, but it is claimed to be due to a genetic predisposition, with an autosomal recessive transmission [2,4].Drover et al. reported the first case to have laparoscopic cholecystectomy with this type of anomaly.Literature reveals very few reports of anomalies of biliary system especially in situs inversus totalis like that of Kamitani et al. who reported aberrant cystic artery running inferior to cystic duct [7].Fabricus in 1600 reported first human case of situs inversus.Situs inversus may be total including abdominal and thoracic viscera (situs inversus totalis), or, more rarely, partial (situs inversus partialis).The transposition of the organs may be associated with other congenital anomalies, such as renal dysplasia, biliary atresia, congenital heart disease, or pancreatic fibrosis.Situs inversus totalis associated with bronchitis, chronic sinusitis, and deficient tracheobronchial cilia is known as the Kartagener's syndrome [8,9].Table 1 has been made  after thorough search from internet which revealed 53 published cases of cholecystectomy in situs inversus.

Conclusions
Asymptomatic or undiagnosed situs inversus with symptomatic gall stone provides a diagnostic dilemma for clinician as the symptoms are predominantly on the left side.
The principles of surgery are the same except for slight modification of port placement.
Switching the dissecting port from epigastric to medial subcostal port facilitates easy gallbladder fossa dissection.

Figure 4 .
Figure 4. Port placements in situs inversus patient for laparoscopic cholecystectomy.

Figure 5 .
Figure 5. Laparoscopic picture of gall bladder in patient of situs inversus.