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CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 145-147

Laparoscopic cholecystectomy in a patient with situs inversus totalis


1 Medical Intern, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Department of Surgery, King Khalid Hospital, Najran, Saudi Arabia
3 Department of Surgery, Hera General Hospital, Makkah, Saudi Arabia

Date of Submission02-Mar-2021
Date of Acceptance22-Jun-2021
Date of Web Publication19-Jul-2021

Correspondence Address:
Dr. Abeer Aljahdali
Medical Intern, Faculty of Medicine, King Abdulaziz University, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_64_21

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  Abstract 

Situs inversus totalis (SIT) is a rare congenital anomaly, in which both the thoracic and the abdominal viscera are transposed to the opposite side of the body. The diagnosis of surgical diseases in patients with SIT is often delayed, leading to complications. Surgery in these patients has been reported to be more challenging for right-handed surgeons. We herein present a case of a 30-year-old woman, not known to have SIT, with a history of intermittent left upper quadrant pain related to food for more than a year. After clinical examination, chest X-ray, and abdominal ultrasound, she was diagnosed with SIT and chronic cholecystitis, and underwent laparoscopic cholecystectomy performed by a right-handed surgeon. We believe that this case report will be informative for surgeons in managing chronic cholecystitis in patients with SIT, and for physicians to always look for clues for SIT in patients presenting with abdominal pain.

Keywords: Chronic cholecystitis, laparoscopic cholecystectomy, right-handed surgeon, situs inversus totalis


How to cite this article:
Aljahdali A, Almowallad S, Habib T. Laparoscopic cholecystectomy in a patient with situs inversus totalis. Saudi Surg J 2020;8:145-7

How to cite this URL:
Aljahdali A, Almowallad S, Habib T. Laparoscopic cholecystectomy in a patient with situs inversus totalis. Saudi Surg J [serial online] 2020 [cited 2021 Dec 8];8:145-7. Available from: https://www.saudisurgj.org/text.asp?2020/8/3/145/321729


  Introduction Top


Situs inversus totalis (SIT) is a condition in which both the thoracic and abdominal viscera are transposed to the opposite side, meaning the apex of the heart lies on the right hemithorax, whereas the liver is on the left and the spleen is on the right side of the abdomen.[1] Its incidence is about 1 in 10,000.[2] The rarity and the nature of this condition pose a challenge in diagnosing and treating surgical diseases.

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic cholelithiasis. However, it can be difficult in patients with SIT, especially for right-handed surgeons.[3]

We herein report a case of chronic cholecystitis in a patient with SIT who underwent laparoscopic cholecystectomy performed by a right-handed surgeon.


  Case Report Top


A 30-year-old woman, not known to have any medical conditions or previous surgical interventions, presented with intermittent left upper quadrant (LUQ) pain related to food for more than 12 months. She made multiple visits to various clinics, and due to the fact that she was never diagnosed with SIT, she was discharged as a case of gastritis.

Physical examination revealed localized tenderness in the LUQ and no clinical jaundice. Abdominal ultrasound (US) showed the liver on the left side [Figure 1], the spleen and stomach on the right side, and a normal-sized gallbladder with thickened wall and few stones, the largest measuring 17 mm. Chest X-ray showed dextrocardia [Figure 2]. The diagnosis of SIT and chronic cholecystitis was made based on the findings of the US and chest X-ray.
Figure 1: Abdominal ultrasound revealing the liver to be in the left side

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Figure 2: Chest X-ray showing dextrocardia

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She was admitted to our hospital, and laparoscopic cholecystectomy was performed.

The surgical approach was modified in the operating room in terms of the position of the patient and port placement [Figure 3]. The patient was positioned head up and left side up for optimum visualization of the gallbladder and Calot's triangle. However, the surgeon was standing on the left side of the patient and the first assistant was standing on the right.
Figure 3: Illustration of the theater setup and port placement

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Four ports were used. The first, 10-mm umbilical port, was inserted using an open technique, and pneumoperitoneum (14 mmHg pressure) was established. A 30° laparoscope was then inserted by the first assistant surgeon, and the presence of SIT was confirmed since the gallbladder was located in its bed under the liver on the left side. Three additional ports were inserted under vision. The first port was inserted 2 cm below the left side of the subxiphoid midline (10 mm). The second port was inserted 5 cm below the subcostal margin of the left midclavicular line (5 mm), and the third port was inserted 5 cm below the costal margin of the left anterior axillary line (5 mm). The port placed on the left side of the subcostal margin of the left midclavicular line was used as the dissection port by the surgeon's right hand, and the port placed below the costal margin of the left anterior axillary line was used for retraction by the surgeon's left hand. The port placed on the left side of the subxiphoid midline was used by the second assistant surgeon to grasp and retract the fundus of the gallbladder. Therefore, Calot's triangle was clearly identified and critical view of safety was obtained. The cystic duct was isolated and clamped with the right hand at a distance of 0.5 cm from the common bile duct. It was then clipped with three titanium clips and cut with the right hand using scissors. The right hand was also used to separate the gallbladder artery with a Maryland dissector, and three titanium clips were also applied to the cystic artery. The gallbladder was separated from its bed by the Maryland dissector and hook alternatively, then successfully removed in a retrograde fashion. The whole operation was performed with the right hand of a right-handed surgeon. Although some difficulties were encountered due to adhesions and the unconventional approach, the operation was completed successfully within 120 min.

Postoperative clinical and laboratory assessment showed that the patient's condition was stable without any complications. The patient recovered quickly and was discharged 2 days postoperatively. Fourteen days later, no abnormalities were observed at the surgical clinic appointment, and histopathologic examination reported the presence of gallstones with chronic cholecystitis.


  Discussion Top


SIT is a rare congenital anomaly, first reported by Fabricius in 1600, in which there is transposition of both the thoracic and abdominal organs to the opposite side of the body.[1] SIT itself does not predispose one to biliary disease but rather delays the diagnosis due to the atypical presentation, specifically the location of pain.[4]

Since Campos and Sipes performed the first laparoscopic cholecystectomy in a patient with SIT successfully in 1991,[5] more than 90 other reported cases were carried out successfully without complications.[6]

In the review of literature, we found that surgeons choose what is suitable for them in terms of port placement and approach to the procedure, since no standard approach has been applied yet. The most common technique used is the four-port technique with mirror-image positioning of the ports and the surgical team, and using either the subxiphoid port or, as in our case, the left midclavicular port for dissection.[6]

To our knowledge, this is the only case where the surgeon was positioned to the left of the patient.

In conclusion, physicians should have a high index of suspicion for SIT in patients presenting with abdominal pain, to prevent complications from delayed diagnosis. In fact, if they were to examine the patient properly, they would find an apex beat located in the right fifth intercostal space, and the liver to be felt in the left side, all of which suggest SIT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors thank Dr. Suzan Alkhodair and Dr. Nadim Malibary for reviewing the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Wood G, Blalock A. Situs inversus totalis and disease of the biliary tract: Survey of the literature and report of a case. Arch Surg 1940;40:885-96.  Back to cited text no. 1
    
2.
Sharma S, Chaitanya KK, Suseelamma D. Situs inversus totalis (dextroversion)-an anatomical study. Anat Physiol 2012;2:112.  Back to cited text no. 2
    
3.
Machado NO, Chopra P. Laparoscopic cholecystectomy in a patient with situs inversus totalis: Feasibility and technical difficulties. JSLS 2006;10:386-91.  Back to cited text no. 3
    
4.
Takei HT, Maxwell JG, Clancy TV, Tinsley EA. Laparoscopic cholecystectomy in situs inversus totalis. J Laparoendosc Surg 1992;2:171-6.  Back to cited text no. 4
    
5.
Campos L, Sipes E. Laparoscopic cholecystectomy in a 39-year-old female with situs inversus. J Laparoendosc Surg 1991;1:123-5.  Back to cited text no. 5
    
6.
AlKhlaiwy O, AlMuhsin AM, Zakarneh E, Taha MY. Laparoscopic cholecystectomy in situs inversus totalis: Case report with review of techniques. Int J Surg Case Rep 2019;59:208-12.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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