Laparoscopic Cholecystectomy in Situs Inversus Totalis

Situs inversus totalis is a rare condition where the organs in the body is placed in the opposite side. When such patient presents with the diseases of the intra abdominal organs the diagnosis is challenging and the operative procedure to be performed will be difficult. This may require the anticipation of variations in anatomy, ergonomic changes required during surgery and mastery over the operative skills in reversed anatomy. Cholelithiasis in situs inversus totalis is one such situation. Herein we report a case of situs inversus totalis who underwent successful laparoscopic cholecystectomy for symptomatic gallbladder calculi. RaghuveeR M N1, MaheSh Shetty S2, SuNil KuMaR B B3, [Table/Fig-1]: USG abdomen [Table/Fig-2]: Situs inversus totalis was confirmed with ECG showing right axis deviation [Table/Fig-3]: ECG obtained after placing the leads exactly in the mirror image of the regular ones [Table/Fig-4]: Chest X-Ray [Table/Fig-5]: CT scan [Table/Fig-6]: Echocardiogram (2D) revealed dextrocardia and no structural and functional abnormalities in the cardia Raghuveer MN et al., Laparoscopic Cholecystectomy in Situs Inversus Totalis www.jcdr.net Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): ND03-ND05 4 The condition may present diagnostic difficulty [2]. Pain of biliary colic may be located in the epigastrium or in the left subcostal region and that of cholecystitis radiates to the left infrascapular region and the left shoulder. It has been noted in 30% of previous reported cases of acute cholecystitis in patients with situs inversus that 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. High degree suspicion is required in such cases [5] . The mirror image anatomy poses difficulty in orientation during laparoscopic cholecystectomy [1,6]. Various laparoscopy ports need to be positioned at sites that are mirror image of those in the usual patient [2]. Second, the surgeon needs to reorient visual images and surgical steps. In the reports described previously the surgeon dissected Significance of position of surgeon to patient – The surgeon stood to the right of the patient to approach the callot’s triangle easily and the law of triangulation was established. But the dissection had to be done with left hand which was difficult. Dissection of callot’s triangle was also tried from the caudal end [2] with patient in Lloyd davis position but was still uncomfortable so the dissection was continued from right side only. The common bile duct, cystic duct and cystic artery were identified. There were no structural abnormalities in these structures. The surgery proceeded uneventfully and the gallbladder was extracted through umbilical port. Total time consumed was 2h 15min. Macroscopically the gallbladder measuring 6cm x 3cm x 2cm was congested oedematous. Cut section revealed partial loss of velvety appearance of mucosa. Multiple pigmented calculi seen in the lumen. Histopathology of sections from the Gallbladder revealed features suggestive of chronic cholecystitis The patient was discharged on 5th postoperative day. He was given oral antibiotics for three days, NSAIDs for three days and proton pump inhibitors for one month. He was reviewed after one week for suture removal and one month later. The patient was asymptomatic. DiSCuSSiOn According to the article published by Vijay Bangaokar there were 36 reported cases of gallbladder pathology managed laparoscopically without any complications [3] [Table/Fig-9] Most of the cases included in the report were situs inversus totalis and few with partial situs inversus with gallbladder on the left side [3]. In the study most cases were females and within age group 20 and 80 years. The indications for surgery was varied from simple cholelithiasis to empyema gallbladder [3]. Our case is 37th one with situs inversus totalis and managed laparoscopically without any complications. In our case the surgery was performed from right side and from the caudal approach. [Table/Fig-7]: A thirty degree storz system 10mm telescope camera in the umbilical region revealed the abdominal contents found on the opposite side [Table/Fig-8]: A 10mm epigastric port was put and two 5mm ports were put in midaxillary and anterior axillary line on left side [Table/Fig-9]: Previous case reports published on laparoscopic cholecystectomy in situs inversus [3,4] S.No author year age in years Sex Diagnosis 1. Campos L 1991 39 Female Cholelithiasis 2. Drover JW 1992 29 Female Cholelithiasis 3. Goh P 1992 62 Male Empyema 4. Huang SM 1992 36 Male Cholelithiasis 5. Lipschutz JH 1992 80 Male Cholelithiaisis choledocholithiasis 6. Takei HT 1992 51 Female Cholelithiasis 7 Schiffino L 1993 53 Female Cholelithiasis 8 McDermott 1994 66 Male Cholelithiasis cholangitis 9 Malatini 1996 25 Female Acute cholecystitis 10 Crosher Rf 1996 63 Male Cholelithiasis 11 Ethomsy G 1996 58 Female Acute cholecystitis 12 D’Agata A 1997 72 Female Cholelithiasis 13 Habib 1998 45 Female Cholelithiasis 14 Demetriadis H 1999 61 Female Acute cholelithiaisis 15 Demetriadis H 1999 37 Male Cholelithiasis 16 Djohan RS 2000 20 Female Cholelithiasis 17 Wong J 2001 68 Female Cholelithiasis choledocholithiasis 18 Al-Jumaily 2001 46 Female Microlithiasis gallbladder 19 Nursal TZ 2001 42 Female Cholelithiasis 20 Donthi R 2001 43 Female Chronic cholecystitis 21 Donthi R 2001 34 Female Cholelithiasis 22 Yaghan RJ 2001 48 Female Cholelithiasis 23 Yaghan RJ 2001 38 Female Cholelithiasis 24 Franklin ME 2001 25 Female Cholelithiasis 25 Polychronidis M 2002 68 Male Cholelithiasis 26 Tronge A 2002 28 Female Cholelithiasis 27 Pitiakoudis M 2005 47 Female Cholelithiasis 28 Das S 2005 40 Female Cholelithiasis 29 Damian Mc Kay 2005 32 Female Acute cholecystitis 30 Kamitani S 2005 76 Male Cholelithiasis 31 Kumar S 2007 57 Female Cholelithiasis 32 Rosen H 2008 36 Male Acute cholecystitis 33 Hamdi J 2009 41 Male Acute cholecystitis 34 Eisenberg D 2009 61 Male Cholelithiasis 35 Jindal V 2010 55 Female Cholelithiasis pancreatitis 36 Bargaonkar V 2010 47 Female Cholelithiasis 37 Present Study 2014 55 Male Cholelithiasis www.jcdr.net Raghuveer MN et al., Laparoscopic Cholecystectomy in Situs Inversus Totalis Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): ND03-ND05 5 PaRtiCulaRS OF CONtRiButORS: 1. Postgraduate Student, Department of Surgical Gastroenerology, JSS Medical College and Hospital, Mysore, India. 2. Assistant Professor and Head, Department of Surgical Gastroenerology, JSS Medical College and Hospital, Mysore, India. 3. Assistant Professor, Department of Surgical Gastroenerology, JSS Medical College and Hospital, Mysore, India. NaMe, aDDReSS, e-Mail iD OF the CORReSPONDiNg authOR: Dr. Raghuveer MN, No. 71, Second Floor,“Sri Rama Complex”, 3rd Cross, D.Devaraj Urs Road Mysore – 570024, Karnataka State, India. Phone: +919916830019, E-mail: dr.raghuveermn@gmail.com FiNaNCial OR OtheR COMPetiNg iNteReStS: None. Date of Submission: Feb 02, 2014 Date of Peer Review: Feb 23, 2014 Date of Acceptance: apr 22, 2014 Date of Publishing: Jul 20, 2014 with his left hand or asked for assistance to grasp the neck of the gallbladder. Retraction on Hartmann’s pouch may be carried out by the assistant, thus allowing the surgeon to operate in a more ergodynamic fashion [1,3]. There is no evidence of bile duct injuries during laparoscopic cholecystectomy in situs inversus totalis [2,3]. RECOmmEnDATiOnS AnD FuTuRE SCOPE There are several important aspects of the management of gallstones in patients with situs inversus that are worth highlighting. • Situs inversus totalis does not appear to be a contraindication [1,4] to laparoscopic cholecystectomy even in case of empyema [3]. • The mirror image anatomy poses difficulty in diagnosis and orientation during laparoscopic cholecystectomy [1,6]. • Though laparoscopic cholecystectomy in such patients is technically more demanding, an experienced laparoscopic surgeon can perform it safely [7]. • Evaluation of vascular anatomical abnormalities may be done which requires CT Angiogram [2]. • Due to requirement of meticulous dissection the time required for surgery is more [2]. • Even a left handed surgeon may also find it difficult to perform this surgery as he is used to a right sided gall bladder. • In future Robotics may prevent this difficulty to some extent. COnCluSiOn In situs inversus laparoscopic cholecystectomy can be performed safely in gallbladder pathologies even in empyema. But the associated anatomical variations of other structures also should be ruled out preoperatively to prevent untoward consequences. The surgeon should be prepared for the reverse orientation during surgery. REFEREnCES [1] McKay D, Blake G. Laparoscopic cholecystectomy in situs inversus totalis: a case report. BMC Surg. 2005;5:5. [2] Senthil Kumar and Giuseppe Fusai. Laparoscopic Cholecystectomy in Situs Inversus Totalis with Left-Sided Gallbladder. Ann R Coll Surg Engl. 2007; 89(2): 186. [3] Vijay D Borgaonkar, Sushil S Deshpande, and Vidyadhar V Kulkarni. Laparoscopic cholecystectomy and appendicectomy in situs inversus totalis: A case report and review of literature. J Minim Access Surg. 2011; 7(4): 242–45. [4] Takei HT, Maxwell JG, Clancy TV, Tinsley EA. Laparoscopic cholecystectomy in situs inversus totalis. J Laparoendosc Surg. 1992; 2:17176. [5] Naikoo GM, Wani I, Mir I, Jan F, Mushtaq S, Ahmad MN. Emergency Cholecystectomy in Situs Inversus Totalis: Report of a Case. Internet Journal of Medical Update. 2008;3(1):50-52. [6] Shah AY, Patel BC, Panchal BA. Laparoscopic cholecystectomy in-patient with situs inversus. J Min Access Surg. 2006;2:27-8. [7] Dan Eisenberg. Cholecystectomy in situs inversus totalis: a laparoscopic approach. International Medical Case Reports Journal. 2009; Volume 2009:2 Pages 27 – 29.

On examination no jaundice or pyrexia was noted. Apex beat was on the right fifth intercostal space in the mid clavicular line. WBC counts and amylase levels were normal. USG abdomen [Table/ Fig-1] revealed left sided gallbladder with multiple calculi. There was no evidence of common bile duct or intrahepatic biliary radicals dilatation.
Situs inversus totalis was confirmed with ECG [Table/ Fig-2] showing right axis deviation. Global negativity in lead I (a negative P-wave, QRS complex and T-wave). Positively deflected QRS complex in aVR. Negative P-wave in lead II. Reverse R-wave progression in precordial leads.The leads were placed in opposite direction and repeat ECG was obtained [ There were no comorbid conditions. Laparoscopic cholecystectomy was planned after obtaining a valid informed written consent. The operating set up and the monitor were placed in the direction opposite to conventional surgery. The operating team also changed their positions, primary surgeon and first assistant were standing on the right side and second assistant was standing on the left side.
Under general anaesthesia on insertion of 10mm thirty degree storz system telescope camera all the contents were exactly found on the opposite side [Table/ Fig-7],10mm epigastric port was put and two 5mm ports were put in midaxillary and anterior axillary line on left side [Table /Fig-8]. The primary operating surgeon was right handed.
He had to crossover his arms to retract the neck of the gallbladder with left hand and dissect the callot's with right hand. To prevent this difficulty the first assistant was asked to retract the neck of gallbladder [1] and the primary surgeon dissected out the callots triangle with right hand [1].

ABSTRACT
Situs inversus totalis is a rare condition where the organs in the body is placed in the opposite side. When such patient presents with the diseases of the intra abdominal organs the diagnosis is challenging and the operative procedure to be performed will be difficult. This may require the anticipation of variations in anatomy, ergonomic changes required during surgery and mastery over the operative skills in reversed anatomy. Cholelithiasis in situs inversus totalis is one such situation. Herein we report a case of situs inversus totalis who underwent successful laparoscopic cholecystectomy for symptomatic gallbladder calculi. The condition may present diagnostic difficulty [2]. Pain of biliary colic may be located in the epigastrium or in the left subcostal region and that of cholecystitis radiates to the left infrascapular region and the left shoulder. It has been noted in 30% of previous reported cases of acute cholecystitis in patients with situs inversus that 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. High degree suspicion is required in such cases [5] .
The mirror image anatomy poses difficulty in orientation during laparoscopic cholecystectomy [1,6]. Various laparoscopy ports need to be positioned at sites that are mirror image of those in the usual patient [2].
Second, the surgeon needs to reorient visual images and surgical steps. In the reports described previously the surgeon dissected Significance of position of surgeon to patient -The surgeon stood to the right of the patient to approach the callot's triangle easily and the law of triangulation was established. But the dissection had to be done with left hand which was difficult. Dissection of callot's triangle was also tried from the caudal end [2] with patient in Lloyd davis position but was still uncomfortable so the dissection was continued from right side only.
The common bile duct, cystic duct and cystic artery were identified. There were no structural abnormalities in these structures. The surgery proceeded uneventfully and the gallbladder was extracted through umbilical port. Total time consumed was 2h 15min.
Macroscopically the gallbladder measuring 6cm x 3cm x 2cm was congested oedematous. Cut section revealed partial loss of velvety appearance of mucosa. Multiple pigmented calculi seen in the lumen. Histopathology of sections from the Gallbladder revealed features suggestive of chronic cholecystitis The patient was discharged on 5 th postoperative day. He was given oral antibiotics for three days, NSAIDs for three days and proton pump inhibitors for one month. He was reviewed after one week for suture removal and one month later. The patient was asymptomatic.

DiSCuSSiOn
According to the article published by Vijay Bangaokar there were 36 reported cases of gallbladder pathology managed laparoscopically without any complications [3] [Table/ Fig-9] Most of the cases included in the report were situs inversus totalis and few with partial situs inversus with gallbladder on the left side [3]. In the study most cases were females and within age group 20 and 80 years. The indications for surgery was varied from simple cholelithiasis to empyema gallbladder [3]. Our case is 37 th one with situs inversus totalis and managed laparoscopically without any complications. In our case the surgery was performed from right side and from the caudal approach.
[Table /Fig-7]: A thirty degree storz system 10mm telescope camera in the umbilical region revealed the abdominal contents found on the opposite side [ with his left hand or asked for assistance to grasp the neck of the gallbladder. Retraction on Hartmann's pouch may be carried out by the assistant, thus allowing the surgeon to operate in a more ergodynamic fashion [1,3].
There is no evidence of bile duct injuries during laparoscopic cholecystectomy in situs inversus totalis [2,3].

RECOmmEnDATiOnS AnD FuTuRE SCOPE
There are several important aspects of the management of gallstones in patients with situs inversus that are worth highlighting.
• Situs inversus totalis does not appear to be a contraindication [1,4] to laparoscopic cholecystectomy even in case of empyema [3].
• The mirror image anatomy poses difficulty in diagnosis and orientation during laparoscopic cholecystectomy [1,6].
• Though laparoscopic cholecystectomy in such patients is technically more demanding, an experienced laparoscopic surgeon can perform it safely [7].
• Evaluation of vascular anatomical abnormalities may be done which requires CT Angiogram [2].
• Due to requirement of meticulous dissection the time required for surgery is more [2].
• Even a left handed surgeon may also find it difficult to perform this surgery as he is used to a right sided gall bladder.
• In future Robotics may prevent this difficulty to some extent.

COnCluSiOn
In situs inversus laparoscopic cholecystectomy can be performed safely in gallbladder pathologies even in empyema. But the associated anatomical variations of other structures also should be ruled out preoperatively to prevent untoward consequences. The surgeon should be prepared for the reverse orientation during surgery.