Single-incision laparoscopic cholecystectomy using conventional instruments in situs inversus totalis

Abstract

Situs inversus totalis is a rare genetic disorder. Single-incision laparoscopic cholecystectomy (SILC) in situs inversus totalis has been reported rarely. SILC has an advantage of being easier than conventional laparoscopic cholecystectomy in addition to better cosmesis and reduced postoperative pain. We report a case of single-incision laparoscopic cholecystectomy done in a young woman with situs inversus totalis using conventional laparoscopic instruments.

Background

Situs inversus totalis (SIT) is a rare genetic disorder characterised by complete transposition of thoracic and abdominal organs on opposite side. The incidence ranges between 1:10 000 and 1:20 000.¹ Laparoscopic cholecystectomy is the gold standard for treatment of symptomatic gallstones but is difficult to perform by a right-handed surgeon in SIT. Single-incision laparoscopic cholecystectomy (SILC) in SIT has very rarely been reported. We describe SILC with conventional instruments in a 23-year-old woman with SIT suffering from symptomatic cholelithiasis.

Case presentation

A 23-year-old female patient presented with history of intermittent left upper abdomen discomfort and dyspepsia since 1 year. There was no history of similar symptoms. There was no medical or surgical history.

Investigations

Abdominal ultrasonography revealed a single gallstone of size 8 mm with gall bladder and liver on the left side, and spleen on the right side. A chest X-ray was performed which revealed dextrocardia (figure 1).

Figure 1.

Chest X-ray of the patient revealing dextrocardia.

Treatment

The patient was taken up for elective surgery.

She was given general anaesthesia and placed in the lithotomy position with the surgeon and the assistant in between the legs of the patient.

A curvilinear infraumbilical skin incision of approximately 2.5 cm size was made (figure 2). Subcutaneous tunnelling was done on either side of midline.

Figure 2.

Figure showing infraumbilical incision.

Pneumoperitoneum established using CO₂ at a pressure of 12. Two 10 mm trocars were inserted, the trocar on the right side of the patient for the laparoscope and on the left side for the working instrument. SIT was confirmed by locating the liver and gall bladder to be on the left side and the spleen, the stomach and heartbeat on the right side (figure 3).

Figure 3.

Diagnostic laparoscopy showing the liver and the lesser curvature of stomach on the left side.

A suture using a straight needle was inserted into the anterior axillary line through the 10th intercostal space on the left side, and the seromuscular layer of the gallbladder fundus was punctured and retracted towards the anterior abdominal wall (figure 4). This suture was used for retraction by the assistant. Hartmann’s pouch was punctured and retracted using the second suture which was inserted in the epigastrium and taken out through the left hypochondrium to expose the Calot’s triangle. The left hand of the surgeon was hence used for retraction of the gall bladder (figure 5).

Figure 4.

Polyglactin suture used for retraction of fundus.

Figure 5.

Another suture used for retraction of Hartmann pouch.

The Maryland forceps was used to dissect the Calot’s triangle. Posterior dissection of Calot’s triangle was done followed by separation of gall bladder from the cystic plate. Once the cystic artery and duct were exposed, the cystic artery and the cystic duct were doubly clipped and cut (figure 6). Monopolar cautery (spatula/hook) was used to dissect the gall bladder from the gallbladder fossa.

Figure 6.

Intraoperative image showing clipping of cystic duct.

The gall bladder was extracted after removal of the suspending sutures from the abdominal wall through the 10 mm port. Rectus sheath was closed with polyglactin no 1 suture. The umbilical incision was closed with metal clips. The procedure took a total of 45 min, and blood loss was minimal.

Outcome and follow-up

The postoperative period was uneventful, and the patient was discharged on postoperative day 1.

Discussion

SIT is a rare genetic abnormality which was first reported by Fabricus in 1600. It is characterised by mirror image of normal position of organs. The incidence of cholelithiasis in SIT is similar to that of a normal person. However, the altered position of the organs may lead to difficulty in diagnosis and orientation and dissection during surgery. This increases the operative struggle, hence increasing the risk of iatrogenic injures and the operative time.²

Conventional laparoscopic cholecystectomy (cLC) is the treatment of choice in symptomatic gall stone disease in a patient with normal anatomy. In cases of SIT, the surgeon needs to orient to lateral and medial relations. Various studies have reported that cLC is more difficult in SIT than in orthotopic patients.³ In right-handed surgeon, the instruments inside peritoneal cavity or hands have to be crossed, and hyperflexion of trunk is required. Certain modifications of cLC is required to decrease the technical difficulty in SIT.³

SILC in SIT has rarely been reported. Various methods of SILC have been reported in the literature. Uludag et al reported a case where they used SILS port with three operating channels.⁴ Bozkurt et al used special reticulating instruments in their case.⁵ In SILC, there is an advantage in SIT as the dissection can be done by right hand.⁴ Surgeons performing SILC in SIT had no intraoperative injuries with an operative time of 75–90 min.^{4 5} In addition, SILC decreases invasiveness, hence decreasing postoperative pain and increasing cosmesis.

We report this case where SILC was done in a case of SIT with conventional laparoscopic instruments and trocars. The surgery was performed by a right-handed surgeon with no intraoperative or postoperative complications with minimal struggle during surgery.

Learning points.

• Situs inversus totalis is a rare genetic abnormality.

• The altered position of organs leads to difficulty in orientation and dissection during surgery.

• Single-incision laparoscopic cholecystectomy in situs inversus totalis has rarely been reported.

• We have devised our own method of single-incision laparoscopic cholecystectomy using conventional laparoscopic instruments with the advantage of better cosmesis, lesser pain and lesser cost.