Laparoscopic cholecystectomy and appendicectomy in situs inversus totalis: A case report and review of literature.

Situs nversus totalis is a rare condition which presents difficulty in clinical diagnosis as well as laparoscopic surgery for cholelithiasis. The mirror image anatomy makes the laparoscopic intervention difficult even for an experienced surgeon. Presenting here is a case report and review of literature.

INTRODUCTION

The first case of situs inversus in humans was reported by Fabricius in 1600.[1] This condition of abnormal visceral rotation was known in animals since the days of Aristotle.[2] The incidence of situs inversus totalis has been thought to be 1:5000 to 1:20000.[25] This condition may affect thoracic organs, abdominal organs or both. It is associated with a number of other conditions such as Kartagener's (bronchiectasis, sinusitis, situs inversus) and cardiac anomalies.[27] There is no current evidence showing increased incidence of cholelithiasis in patients with situs inversus totalis.[4]

After Mouret performed first laparoscopic cholecystectomy in 1987, it has become a gold standard in treatment of cholelithiasis. The first known laparoscopic cholecystectomy in situs inversus has been reported by Campos and Sipes in 1991.[1] Due to the very nature of reversed anatomy and possibility of associated anomalies the procedure is technically demanding even for an experienced laparoscopic surgeon.[311]

CASE REPORT

A 47-year-old female presented with pain since 15 days in left hypochondrium and left iliac fossa region. Patient was haemodynamically stable, afebrile and non icteric. She had tenderness in left iliac fossa and there was no palpable mass. Her total leukocyte count was raised. Ultrasonogrphy of abdomen revealed cholelithiasis with probe tenderness at left McBurney's point with situs inversus. X-ray chest revealed dextrocardia with fundic gas shadow on right side. [Figure 1]. Computed tomography (CT) thorax and abdomen revealed situs inversus totalis. [Figure 2]. She was posted for laparoscopic cholecystectomy and appendicectomy. Or arrangement - mirror image of routine laparoscopic cholecystectomy. Anaesthetist was at the head end, monitor was placed on the patient's left side and surgeon with camera assistant was on the right side of the patient. Port position is a mirror image of routine four port lap-cholecystectomy. [Figure 3]. A 10 mm camera port was placed at supraumbilical region, epigastric 10 mm port to the surgeon's left and right hand as and when necessary. A 5 mm mid clavicular port to the surgeon's right hand occasionally to be hold by assistant. A 5 mm port was placed in the anterior axillary line at the level of umbilicus for gall bladder retraction. Calot's triangle was visualised by retracting infundibulum. Posterior surface of Calot's triangle was visible better than the anterior surface.

Figure 1

X-ray chest showing dextro cardia

Figure 2

CT scan showing left sided liver

Figure 3

Port position

Operating instruments, hook with diathermy was passed from epigastric port and managed with right/left hand of surgeon while traction at infundibulum was exerted by the assistant. Cystic artery was managed by harmonic. Cystic duct was clipped and divided after obtaining critical view at Calot's triangle. [Figures 4 and 5]. Dissection at fossa was done by surgeon's right hand at mid clavicular port and gall bladder manipulated by surgeon's left hand through epigastric port. Specimen was retrieved through epigastric port.

Figure 4

Intra operative picture showing gall bladder on left of Ligamentum Teres

Figure 5

Dissection of cystic duct

For simultaneous appendicectomy, same ports were used even though the positions were cumbersome. Anterior axillary port was used for surgeon's right hand, while for left hand; mid-clavicular port was used. Appendix with cecum was visualised in the left iliac fossa region somewhat high up in position. Appendicectomy was performed using harmonic scalpel. Base was ligated with loop ligature and divided. Specimen was retrieved through port. Operating time was one hour and there was no blood loss.

DISCUSSION

Situs inversus is a congenital condition. It can either be partial or total. This entity is considered to have a genetic predisposition that is autosomal recessive with the defect being localised on the long arm of chromosome 14.[8]

There is no evidence that situs inversus predisposes to cholelithiasis, but it may be a cause of diagnostic confusion. Delay in the diagnosis was due to the left upper abdominal pain and unknown situs inversus.[6] Internet search has revealed 36 reported cases of cholecystectomy in situs inversus including our case [Table 1]. Of these, 11 are males and 25 are females. This indicates that gall bladder disease is predominant in females even in situs inversus. The age group is from 20 to 80 years. Of the reported cases, 26 are situs inversus totalis, while in 4 cases; the condition has not been specified. The remaining 4 cases are partial. Previous reports have confirmed that situs inversus is not a contraindication for laparoscopic cholecystectomy.[2] The procedure becomes difficult because of the fact that the anatomy is mirror image of that of routinely seen and most surgeons are right handed. This needs alteration in technique of cholecystectomy.[10] When chances of about 25% biliary anatomical variations are considered, the chances of iatrogenic injuries increases.[8]

Table 1

Publications on Situs Inversus and Laparoscopic Cholecystectomy

The dissection is difficult, as commonly used right hand has to be used for retraction and left for dissection. If this anatomical variation makes the picture confusing, then early conversion should be thought. In our patient, appendicectomy was performed as the patient had pain in the left iliac fossa region.

A number of papers have suggested different port positions, but we used mirror image of standard laparoscopic cholecystectomy ports. The alteration in working hand position occasionally was necessary.

The PubMed search has revealed the use of laparoscopy for various procedures in cases of situs inversus. Laparoscopy has been reported for gastric banding,[12] lap assisted gastropexy in a child.[13] Hemicolectomy, distal gastrectomy, fundoplication has also been done laparoscopically. The difficulties faced by all the surgeons are mainly because of the mirror image anatomy and change in the use of the dominant hand while dissecting.

In conclusion, laparoscopic cholecystectomy in patients of situs inversus totalis is a safe procedure. It needs modification in technique, proper planning and with cautious dissection; the procedure can be safely completed.