Laparoscopic cholecystectomy in situs inversus totalis

Summary

Situs inversus totalis is a rare congenital anomaly in which the thoracic and abdominal viscera are transposed in mirror image, placing the gallbladder in the left upper quadrant. Laparoscopic cholecystectomy is consequently demanding for the right-hand-dominant surgeon, who, using a conventionally mirrored setup, would be required to dissect with the non-dominant hand, accept crossing of the operating instruments, or delegate retraction to an additional assistant. We describe a woman in her 40s with situs inversus totalis and symptomatic cholelithiasis who underwent an elective laparoscopic cholecystectomy using a configuration in which the surgeon operated from the patient’s left with both working ports placed subcostally. This allowed dominant-hand dissection while the surgeon retained infundibular retraction, enabling the procedure to be completed safely with a single assistant. The critical view of safety was achieved and the patient’s recovery was uneventful. An annotated operative video accompanies this report as a teaching resource.

Background

Situs inversus totalis is a rare congenital anatomical anomaly with a reported incidence of approximately 1 in 10 000, in which the thoracic and abdominal viscera are transposed in mirror image.¹ It is distinct from partial situs inversus and from situs ambiguus (heterotaxy), the latter characterised by isomerism and indeterminate laterality. Complete and concordant reversal of the viscera without the indeterminate features or isomerism of situs ambiguus confirms situs inversus totalis.¹

The mirror inversion caused by situs inversus totalis places the gallbladder in the left upper quadrant, making laparoscopic cholecystectomy technically demanding for the right-hand dominant surgeon, for whom simply mirroring the standard port and personnel arrangement tends to force dissection with the non-dominant hand or crossing of the operating instruments.² A range of operative adaptations has been described to mitigate this, and no single configuration has been adopted as standard.² The reported techniques and the manoeuvres they use to preserve dominant-hand dissection are compared in the Discussion section (table 2).

In the present case, we describe a configuration in which the surgeon operated from the patient’s left with both working ports placed subcostally, allowing the right-hand-dominant surgeon to dissect with the dominant hand and to perform the procedure with a single assistant. An annotated operative video accompanies this report.

Case presentation

A woman in her 40s was referred to our hepatobiliary and pancreatic surgery department by the general surgical department of a regional hospital. She had been initially referred to that regional hospital for management of her worsening biliary colic. An ultrasound scan in the preoperative workup found cholelithiasis and situs inversus, which was later confirmed as the situs inversus totalis subtype by CT scan. The regional surgical team referred to our tertiary centre due to the variant anatomy which would require modifications to the standard operative approach.

On review, it was revealed that the patient had been suffering from postprandial pain for the last 3 years, which was associated with nausea and vomiting. The pain had become more frequent with increasing intensity over the last year. The pain was present in the patient’s left upper quadrant, in keeping with the patient’s variant anatomy, but would radiate across to the right upper quadrant at times. Abdominal examination at this review was unremarkable. In addition to her situs inversus totalis, the patient had a known history of type 2 diabetes mellitus, hypertension and a previous caesarean section.

The patient was listed for an elective laparoscopic cholecystectomy.

Investigations

The patient’s preoperative ultrasound scan revealed situs inversus. A thin-walled gallbladder was noted to be mildly tender to palpation. Cholelithiasis was seen, with the gallbladder containing multiple small mobile calculi up to 5 mm in diameter. Comet tail shadowing was observed relating to the anterior wall of the gallbladder in keeping with adenomyomatosis of the gallbladder.

Preoperative contrast-enhanced CT was performed to characterise the variant anatomy and confirmed situs inversus totalis, demonstrating a left-sided liver, right-sided spleen and reversed position of the pancreas, with dextrocardia (figure 1). The abdominal and mesenteric vasculature was reversed in concordant fashion, without azygos continuation or duplication of the inferior vena cava. There was no intestinal malrotation—an anomaly that arises from a separate embryological process and is independent of situs inversus¹—and no further gross vascular variant. The complete and concordant reversal without indeterminate features confirmed situs inversus totalis rather than situs ambiguus.

Figure 1. Preoperative contrast-enhanced coronal CT demonstrating situs inversus totalis. (A) Anterior slice showing the left-sided liver and gallbladder, right-sided stomach and dextrocardia. (B) Posterior slice showing the left-sided liver and right-sided spleen. Images from the authors’ institution; annotations added by the authors.

Preoperative liver function tests showed a mild elevation in alanine aminotransferase and a marginal elevation in aspartate aminotransferase with otherwise preserved hepatobiliary indices (table 1). This pattern was consistent with the clinical impression of biliary colic. Full blood count and serum electrolytes were within normal limits.

Table 1. Preoperative serum chemical pathology.

Chemical pathology analyte	6 months before surgery	1 week before surgery	Local reference range (adult woman)
Total bilirubin (μmol/L)	8	11	1–20
Alanine transaminase (U/L)	Not recorded	58	5–35
Aspartate aminotransferase (U/L)	20	33	5–30
Alkaline phosphatase (U/L)	67	97	30–110
Gamma-glutamyl transferase (U/L)	34	28	5–35

The gallbladder and biliary tree appeared unremarkable on CT scan despite the sonographic findings, illustrating the lower sensitivity of CT scan for cholelithiasis. The diagnosis of symptomatic cholelithiasis was made sonographically and was clinically supported by the history of recurrent postprandial pain and the biochemistry.

Differential diagnosis

The patient’s presentation of chronic, postprandial, left upper quadrant pain required careful interpretation in the context of her known situs inversus totalis. In a patient with normal anatomy, left upper quadrant pain would not typically raise a clinical suspicion of biliary pathology, and the reversed position of the gallbladder in situs inversus totalis is a recognised source of diagnostic confusion and delay.^3–5 Recognising that the mirror-image anatomy placed the gallbladder, and therefore the biliary pain, in the left upper quadrant was central to correctly attributing her symptoms.

The postprandial timing, colicky nature and associated nausea were characteristic of biliary colic, and the mild hepatocellular derangement in liver function tests, without cholestatic features, argued against common bile duct obstruction. Pancreatitis was considered given the upper abdominal radiation of the pain but was thought unlikely in the absence of severe or persistent pain. Peptic ulcer disease was also considered, but the episodic, postprandial, colicky character of the pain was more in keeping with biliary origin. The chronicity of symptoms over several years, without features of malignancy or weight loss, further supported a benign biliary cause.

Treatment

The patient presented on their elective surgical date as planned. After anaesthetic induction, the patient was positioned supine with both arms out. The surgeon was positioned on the patient’s left side, while the assistant was positioned on the right. The laparoscopic stack was positioned at the patient’s right while a secondary screen was positioned over the patient’s left shoulder. Ports were placed in a mirrored configuration relative to our standard approach—sub-umbilical 10 mm (camera), high epigastrium 5 mm and two subcostal ports 5 mm with location decided by the location of structures and to maximise triangulation (figure 2D). The right-hand dominant assistant operated the camera via the sub-umbilical port (right hand) and retracted the gallbladder fundus via the epigastric port (left hand). The surgeon operated in a right-hand dominant fashion, with their right hand using the lateral-most subcostal port to perform the dissection and their left hand retracting via the medial subcostal port. There was good triangulation of operating ports using this technique, with no instrument clash on lateral dissection of the gallbladder (figure 3). Medial dissection was slightly more challenging and there was some crossing of instruments. This challenge was overcome with good retraction, and medial dissection was completed without needing to change the position of the surgeon and assistant (figure 4). The cholangiogram catheter was inserted via the medial subcostal port using the surgeon’s left hand, as is routinely performed in our institution for standard cholecystectomy. Intraoperative cholangiography showed hepatic trifurcation with good flow and no filling defects (figure 5).

Figure 2. Schematic comparison of operative configurations for laparoscopic cholecystectomy in situs inversus totalis, viewed from above with the patient supine. (A) Non-dominant hand dissection, in which the surgeon dissects with the left hand through the epigastric port to avoid crossing. (B) Dominant-hand dissection through the epigastric port, requiring the surgeon’s instruments to cross. (C) Dominant-hand dissection through the epigastric port with infundibular retraction delegated to a second assistant, requiring two assistants. (D) Present case configuration, with the surgeon on the patient’s left and both working ports placed subcostally, allowing dominant-hand dissection and infundibular retraction from adjacent same-side ports with a single assistant. Coloured circles indicate the surgeon’s and assistant’s hands, matched by colour to the port each hand operates. Panels A–C are schematic representations of the compromises described in the literature rather than depictions of individual reported cases; other reported configurations are summarised in table 2. Figures were drawn by the authors. A, assistant; C, camera port; D, dissecting port; R, retracting port; S, surgeon.

Figure 3. Intraoperative view during lateral dissection of the gallbladder, demonstrating triangulation of the operating ports without instrument clash. Image from the authors’ institution; annotations added by the authors.

Figure 4. Intraoperative view during medial dissection of the gallbladder, where the instruments converged most closely; this was managed with careful retraction without repositioning of the surgeon or assistant. Image from the authors’ institution; annotations added by the authors.

Figure 5. Intraoperative cholangiography, demonstrating mirrored biliary tree anatomy and hepatic trifurcation. Image from the authors’ institution; annotations added by the authors.

The operative duration was 57 min.

Outcome and follow-up

The patient was reviewed as an inpatient on the day after their surgery as is standard practice at our facility. The patient understandably had appropriate abdominal postsurgical tenderness that was not out of keeping with expected postoperative course. The patient remained haemodynamically stable and afebrile on the ward before being discharged home the day after their surgery.

Histopathology from the operative specimen demonstrated thickening of the muscularis mucosa of the gallbladder wall, with Rokitansky-Aschoff sinuses and adenomyomatous hyperplasia, confirming the adenomyomatosis suggested by the comet-tail shadowing on ultrasound. There was no evidence of epithelial dysplasia or malignancy. Overall, these histopathological findings were in keeping with chronic cholecystitis.

The patient presented for their 6-week postoperative outpatient appointment and had recovered well. She was tolerating her normal diet well, and her postprandial pain had improved. The histopathological findings were conveyed to the patient, and she was discharged from our outpatient service back to her general practitioner.

Discussion

Laparoscopic cholecystectomy in situs inversus totalis is widely reported as technically challenging for the right-hand dominant surgeon. In the conventional mirror-image setup, the surgeon stands to the patient’s right side, and the dissecting instrument is directed through the epigastric port. Reversed anatomy obliges the surgeon to either use their non-dominant left hand to perform the dissection^{2 6} (figure 2A), or alternatively if the dominant right hand is to be used for dissection, the surgeon is forced to cross hands (figure 2B) or else relinquish infundibular retraction to an assistant in place of their left hand³ (figure 2C). Several authors have described the crossing of instruments as the central ergonomic difficulty,^{3 4 7 8} and some case reports have described referring these patients to left-hand dominant surgeons for this reason.² No single configuration has been adopted as standard; the reported approaches vary in surgeon position, port placement and hand-port-instrument assignment. The largest synthesis to date found no significant association between operative technique and operative duration.²

Reported solutions to this ergonomic problem can be grouped by the manoeuvre used to preserve dominant-hand dissection (table 2). One approach relocates the dominant hand to a subcostal port while the surgeon remains on the patient’s right.^{5 7–9} Another approach delegates retraction entirely to a second assistant, freeing the dominant hand to dissect through the epigastric port and thereby requiring two assistants.³ Some authors have used a variant of the Mirrored French approach, positioning the surgeon between the patient’s legs, to allow the surgeon to operate with both hands without crossing.^{2 4} A posterior tunnelling approach to Calot’s triangle has also been described as a means of establishing the required critical view when anterior dissection is awkward in the mirrored field.^{5 9} Notably, the hand-port-instrument assignment is inconsistently reported across these accounts,^{2 10} and even the ‘mirrored American’ configuration is described variably with respect to which hand dissects through which port.^{4 5}

Table 2. Comparison of operative configurations for laparoscopic cholecystectomy in situs inversus totalis.

Configuration (source)	Patient positioning	Surgeon side	Surgeon’s hands (activity, port)	Port configuration	Assistants (side)	Video available
Present case	Supine	Left	Right (dissection, lateral subcostal); Left (retraction, medial subcostal)	Umbilical (optic); epigastric; left subcostal medial; left subcostal lateral	Single assistant (right) – camera+fundal retraction	Yes
‘Mirrored American’2	Supine	Right	Left (dissection, epigastric)	Umbilical (optic); epigastric; 1-2 left subcostal ports	Two – camera (right)+assistant (left)	N/A
‘Mirrored French’2 4	Lithotomy	Between legs	Not specified	Umbilical (optic); epigastric; left AAL (above iliac spine); paramedian (right of midline)	Two (per Lakhey) – camera (left)+retraction (right)4	N/A
Enciu et al2	Lithotomy	Between legs	Both hands dissecting ‘as the situation demanded’*	Umbilical (optic); epigastric; left subcostal MCL; left AAL	Two – camera (right)+retraction (left)	No
Cunningham et al10	Supine	Right	Right (dissection)*; Left (clipping via epigastric)	Umbilical (optic); epigastric; left subcostal medial; left subcostal lateral	Two – camera (right)+assistant (left)	No
Du et al3	Supine	Right†	Right (dissection, epigastric)	Umbilical (optic); epigastric; left subcostal MCL; left AAL	Two – retraction+camera (sides not specified)	No
Matsumoto et al9	Open-leg position (degree of flexion not specified)	Right	Hands alternate around posterior tunnelling technique (epigastric+subcostal MCL)	Umbilical (optic); epigastric; left subcostal MCL; left subcostal AAL	Two – camera (between legs) + assistant (left)	No
Matsuura et al7	Supine	Right	Right (dissection, left AAL); left (retraction, right abdominal)	Umbilical (optic); right abdominal; left subcostal MCL; left AAL	One assistant (left); camera staffing not specified	No
Simkhada et al case 18	Supine†	Right	Right (dissection, MCL); left (retraction, epigastric)	Umbilical (optic); left epigastric; left subcostal MCL; left subcostal AAL	One assistant (left, retraction); camera staffing not specified	No

Surgeon side is relative to the patient.

‘Umbilical’ encompasses subumbilical/supraumbilical/periumbilical/transumbilical placements. ‘Epigastric’ encompasses low epigastric, high epigastric and subxiphoid placements.

^* Port-hand assignment not specified.

^†Implied, not explicitly stated.

AAL, anterior axillary line; MCL, midclavicular line.

In the present case, the surgeon stood on the patient’s left with both working ports placed subcostally, so that the dominant right hand dissected through the lateral subcostal port while the left hand retracted the infundibulum through the adjacent medial subcostal port (figure 2D). Because both instruments approached the operative field from adjacent, same-side origins, crossing was largely avoided; the instruments converged only during the medial dissection, which was overcome with careful retraction. This contrasts with configurations in which dominant-hand dissection through the epigastric port requires a reach across the midline. A direct consequence of retaining infundibular retraction on the surgeon’s left hand is that only the roles of fundal retraction and camera operation remain to be covered, which a single assistant positioned on the patient’s right was able to accomplish through the epigastric and umbilical ports respectively. Configurations that commit the dominant hand to the epigastric port cannot retain the surgeon’s left hand for retraction without crossing, necessitating at least two assistants.³ The present configuration therefore preserves dominant-hand dissection while reducing the assisting requirement to a single individual, which may be of practical value where operative staffing is limited.

The principles of safe dissection were unchanged from conventional cholecystectomy: anatomical cross-checking, dissection above Rouvière’s sulcus and confirmation of the critical view of safety were performed as in the standard operation, with the caveat that the view of Calot’s triangle is approached from lateral to medial, the mirror of the routine orientation.^{9 10} Had the dissection proven too difficult, other strategies were also available, including adopting one of the other reported operative configurations, or conversion to open operation.

This report is limited to a single case and provides no objective or comparative ergonomic data. Therefore no claim of ergonomic superiority is made, and the single-assistant arrangement is presented as feasible in this case rather than as established across cases.

Learning points.

• Laparoscopic cholecystectomy in situs inversus totalis is ergonomically challenging for the right-hand-dominant surgeon, who with the standard mirrored approach must dissect with the non-dominant hand, accept crossing of instruments, or delegate retraction to an additional assistant.

• Placing the surgeon on the patient’s left with both working ports subcostal allows the dominant hand to dissect and the surgeon’s own left hand to retract the infundibulum from adjacent same-side ports, largely avoiding instrument crossing.

• Because the surgeon retains infundibular retraction, only fundal retraction and camera operation remain to be covered, allowing the procedure to be performed with a single assistant; this is of potential value in situations where operative staffing is limited.

• The principles of safe dissection, including the critical view of safety and use of anatomical checkpoints, remain unchanged; only the visuospatial orientation (lateral-to-medial) and the ergonomics of access differ.

• An annotated operative video provides a reproducible reference for a rare scenario that most surgeons would only encounter infrequently (online supplemental file 1).