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Laparoscopic Cholecystectomy in Situs Inversus Totalis

MM Begani*, S Agarwal**, TN Row***
 

Introduction
The first documented case of situs inversus in humans was reported by Fabricius in 1600.1 The incidence of siatus inversus totalis varies from 1:5000 to 1:20000.2

Situs inversus may involve thoracic organs and/or abdominal organs. Sometimes, they are associated with other cardiac anomalies.

Aim
We aim to present the diagnostic dilemma and technical difficulties encountered during laparoscopic cholecystectomy in a case of situs inversus totalis, presenting with acute cholecystitis and cholelithiasis, along with the review of literature.

Presentation
A 42 year old male patient presented with complaints of pain in the epigastric region with dyspepsia and two episodes of vomiting, no fever. Complaints of pain radiating to the right hypochondrium on ingestion of heavy or fatty meal was very typical of cholecystitis. A clinical diagnosis of acute cholecystitis was provisionally made and the patient hospitalized for investigation and treatment.

Patient was from a remote village of central India, it was a very first occasion for him to be hospitalized. No investigations were done on him earlier, therefore, X-ray chest and abdomen, done as the first line of investigation revealed dextrocardia and situs inversus showing the fundic gas in the right side and the liver shadow on the left.

USG revealed multiple gall stones, normal CBD, but, on the left! The liver in the left and the spleen in the right.

Biochemical analysis was within normal limits. ECG revealed a right axis deviation with mild right ventricular hypertrophy.

Patient had no medical problems and was taken for surgery, laparoscopic cholecystectomy was planned. Complete mirroring in the OT, with placements in relation to the patient: video-monitor trolley was positioned on the left side instead of the right and the operating surgeon and assistant surgeon stood on the right of the patient.

The ports were placed as usual, only difference was that they were placed on the left side of the abdomen. Difficulty was encountered initially due to re-orientation needed for the situs inversus and the right handed surgeon. The Hartman’s pouch was retracted by the assistant surgeon, thus avoiding the crossing of the hands of the surgeon. The rest of the operation went off smoothly as usual.

The patient did not require a drain and was discharged in 48 hours, with early return to work.

Discussion
The two rare conditions known are the situs inversus viscerum-totalis or partialis, are diagnostic dilemmas, especially in a case presenting with gall stone dyspepsia.3 In 30% of previous reported cases of acute cholecystitis in patients with situs inversus, the pain was felt in the epigastrium alone and in 10% the pain was localised to the right upper quadrant. The proposed explanation for this is that the central nervous system may not share in the general transposition.4

The technical difficulties encountered due to disorientation of the operating surgeon to the mirror-imaging and change of his position while operating should be appreciated. Though a laparoscopic surgeon is trained to be ambidextrous, most of the surgeons are right handed and so are the instruments. The surgical ease of a left handed surgeon, operating a case of situs inversus, has also been reported in the literature.5

This difficulty can be over come by allowing the first assistant to handle the instrument retracting the Hartman’s pouch, while dissecting the Calot’s triangle. This simple modification on the surgeon’s part makes it easier for the adaptation to the changes of the mirror-imaging during surgery.

Conclusion
In conclusion, we can say, that, though technically, laparoscopic cholecystectomy is difficult for the surgeon and his team, it is not a contraindication.

Once you are aware of the diagnostic dilemma, a little time spent in orienting the operating room and adjusting the instrumentation during surgery, laparoscopic cholecystectomy can be safely performed in a case of situs intersus totalis.

References

  1. Yaghan RJ, Gharaibeh KI, Hammori S: Feasibility of laparoscopic cholecystectomy in situs inversus. J Laparoendosc Adv Surg Tech 2001; 11 (4) : 233-7.
  2. Nursal TZ, Baykal A, Iret D, Aran O. Laparoscopic cholecystectomy in a patient with situs inversus totalis. J Laparoendosc Adv Surg Tech 2001; 11 (4) : 239-41.
  3. Case report: laparoscopic cholecystectomy in situs viscerum inversus; Docimo G, Manzi F, Maione L, Canero A, Veneto F, Lo Schiavo F, Sparavigna L, Amoroso V, De Rosa M, Docimo L, Hepatogastroenterology 2004; 51 (58) : 958-60.
  4. Rao PG, Katariya RN, Sood S, Rao PLNG. Situs inversus totalis with calculus cholecystitis and mucinous cystadenomas of ovaries. J Postgrad Med 1977; 23 : 89-90.
  5. Laparoscopic cholecystectomy in situs inversus totalis: The importance of being left-handed. Oms LM, Badia JM. Surg Endosc 2003; 7 (11) : 1859-61.

 

COILING OR CLIPPING

`Some patients should be clipped and some should be coiled and the ultimate decision is complex'
The International Subarachnoid Aneurysm Trial (ISAT) compared neurosurgical clipping with endovascular coiling in patients with ruptured intracranial aneurysms. In this week's issue of The Lancet, Andrew Molyneux and colleagues, for the ISAT Collaborative Group, reported the primary outcome data at 1 year for all patients. Although both procedures were anatomically suitable for treatment of intracranial aneurysms, endovascular coiling led to significant reduction in the relative risk of death or dependency at 1 year compared with neurological clipping. In a Comment, Gavin Britz states that management of patients with cerebral aneurysms will now be improved with the addition of validated endovascular coiling as another viable treatment option.

Lancet, 2005; 4 : 783, 809.

*Consultant Surgeon, Bombay Hospital Institute of Medical Sciences, Mumbai; **Consultant Surgeon, Agarwal Hospital, Raipur, Chatisgarh; ***Consultant Surgeon, Abhishek Day Care Institute and MRC, Cooperage, Mumbai.
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