Effective Port Placement for Left Sided Gallbladder Cholecystectomy

Abstract

Introduction:

Left sided gallbladder (sinistroposition) is a well described congenital abnormality that can pose an unexpected challenge for the surgeon, especially regarding port placement for safe and effective dissection.

Case Description:

In this case, a 36 -year-old woman with biliary colic was taken to the operating room for elective cholecystectomy and found, after port placement, to have sinistroposition of the gallbladder. The operation was completed with relative ease using our typical port placement of a 5 mm port at Palmer’s point, a 12 mm port at the umbilicus; and two additional 5 mm ports, one in the right midclavicular line, and one in the right anterior axillary line.

Discussion:

Multiple port placements for safe and effective dissection of a left sided gallbladder have been discussed. Identification of sinistropic gallbladder often occurs after ports are already placed in position for right sided cholecystectomy. In this case, our typical port placement where the operating surgeon’s right-hand port is located at Palmer’s point provided excellent positioning for dissection. No alterations to the surgeon’s left-hand port or the assistant port were necessary. The dissection was able to be completed from familiar angles, so dissection and identification of anatomy was performed with relative ease. This is important as sinistroposition can at times lead to abnormalities of the biliary tree, though none were noted in this case.

INTRODUCTION

Left sided gallbladder (sinistroposition) is a well described, although rare, congenital abnormality in which the gallbladder lies to the left of the falciform ligament without situs inversus.¹ Often, pre-operative imaging does not identify malposition of the gallbladder, and it is not until surgery that the anatomical variant is identified. In a case review of six left sided cholecystectomies, only one was identified pre-operatively. Location of pain offers no clue, as biliary pain remains right sided. Pre-operative ultrasound and endoscopic retrograde cholangiopancreatography typically do not identify sinistroposition. With a reported 00.3% prevalence, further investigative work beyond that standard for biliary disease is not indicated.^1,2,4 Safe and effective laparoscopic cholecystectomy of sinistropic gallbladder can be performed with typical right sided port placement; however, port placement modifications may be necessary with several case reports recommending the right-hand operating port be placed well to the left of midline.^1,2,4 As with any laparoscopic operation, appropriate port placement is critical to the ease and safety of dissection. Multiple port placements have been described for both left sided gallbladder and situs inversus including one case at this institution using single port laparoscopic cholecystectomy with effective and safe results.^1–3 In this case we were able to use our typical port placement to our advantage with the surgeon’s right-hand port at Palmer's point to safely complete the case without adjustment or addition of ports.

CASE DESCRIPTION

A 36 -year-old woman was seen in clinic for persistent, intermittent biliary colic. She had a past surgical history of two cesarean sections and tubal ligation. She had no past medical history. Her symptoms included right upper quadrant burning after fatty meals with some improvement after dietary modifications. She denied nausea, vomiting, diarrhea. On review of recent labs, she had no leukocytosis, no liver function test derangements and no elevation in total bilirubin. An ultrasound report from an outside hospital was reviewed reporting a 2.3 × 10.6 cm stone within the gallbladder with posterior acoustic shadowing. There was no gallbladder wall thickening, no pericholecystic fluid, and no common bile duct dilation. The patient was consented for laparoscopic cholecystectomy and was electively taken to the operating room.

In the operating room the patient was approached in our standard manner. This included Veress needle placement and insufflation at Palmer's point via a 5 mm incision. Once insufflation was achieved, the Veress needle was removed, and a 5 mm optical view trocar placed under direct visualization at the Palmer’s point incision. We continued with our typical port placement. A 12 mm radially dilating trocar was placed at the umbilicus. We placed two additional 5 mm ports, one in the right midclavicular line, and one in the right anterior axillary line (Figure 1). This is the standard port placement for the operating surgeon for all cholecystectomies. The gallbladder was not identified in its typical position to the right of the falciform ligament. We placed the patient in a reverse Trendelenburg. After further investigation the gallbladder was present on the left side of the falciform ligament. No other organ transposition was noted and the gallbladder was determined to be in true sinistroposition (Figure 2). The two right lateral retractors were used with relative ease when brought under the falciform ligament and the left sided trocar at Palmer’s point was in optimal position for dissection on the left side of the falciform (Figures 3 and 4). We were then able to complete our laparoscopic cholecystectomy in a standard fashion despite the unusual position of the gallbladder.

Figure 1.

Veress needle placement and insufflation at palmer's point via a 5 millimeter incision. A 5 millimeter optical view trocar placed under direct visualization at the palmer’s point incision. A 12 millimeter radially dilating trocar was placed at the umbilicus. Two additional 5 millimeter ports, one in the right midclavicular line, and one in the right anterior axillary line.

Figure 2.

Gallbladder on left side of falciform being elevated with grasper via right anterior axillary line port for dissection.

Figure 3.

Right hand via palmer’s point port manipulating gallbladder for dissection.

Figure 4.

Gallbladder with cystic duct (Posterior) and cystic artery (Anterior) dissected.

DISCUSSION

Multiple port placements for safe and effective dissection of a left sided gallbladder have been discussed including French style and single port cholecystectomy or moving ports after identification of the sinistropic gallbladder.^1–3 However, pre-operative planning is often not feasible since identification of sinistropic gallbladder does not occur until ports are already placed in position for typical right-sided cholecystectomy. In this case, our typical port placement, where the operating surgeon’s right-hand port is located at Palmer’s point, provided excellent positioning for dissection on the left side of the falciform ligament. The operating surgeon places the operating right-hand port at Palmer’s point as the standard approach to laparoscopic cholecystectomies due to ease with abdominal entry via Veress needle and Optiview placement of a 5 mm port. The angle for dissection works well for standard cholecystectomies, and the camera and right-hand do not collide. No alterations to the surgeon’s left-hand port or the assistant port were necessary when the gallbladder was identified to the left of the falciform ligament, true sinistroposition. The gallbladder was able to be retracted and dissected from angles that were familiar to the surgeon, which is critical to safe dissection and identification of the cystic duct and artery. With our port placement, we were able to identify the cystic duct and artery traveling from right to left, the typical variation for left sided gallbladders. The cystic artery courses from the right to left in front of the common bile duct to the left sided gallbladder. The cystic duct may come from the left or right side of the common bile duct; however, it does not need to be traced to origin.⁴ Our port placement enabled excellent retraction, dissection and ergonomic positioning of the surgeon making identification of critical structures straightforward. This allowed for a safer operation given the risk of bile duct injury is higher in left-sided cholecystectomies.⁵

CONCLUSION

Although rare, left sided gallbladder (sinistroposition) can be safely removed laparoscopically. Optimal port placement is debated. Our typical port placement with the surgeon’s right hand at Palmer’s point (to the left of the falciform) enabled laparoscopic cholecystectomy to be safely and ergonomically performed without alteration or addition of ports. The dissection was able to be completed from familiar angles, so dissection and identification of anatomy was performed with relative ease. This is important as sinistroposition can at times lead to abnormalities of the biliary tree, though none were noted in this case.