Page 12 - WJOLS - Laparoscopic Journal

Sardar H Arif

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surgeon. Dissection from the mid-clavicular cannula with
right hand with the lateral displacement of the neck of the
gallbladder using the left hand through the subxiphoid
cannula is difficult because the tip of the dissector will lose
its perpendicular angle to the dissection plane and become
positioned with a very narrow angle. We performed the
dissection from mid axillary’s cannula. The dissection was
quite safe and this confirms the previous reports of safe
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laparoscopic cholecystectomy in situs inversus totalis. No
matter which configuration is used, it is important to clearly
dissect the cystic duct and artery, stay close to the inferior
gallbladder edge, and obtain the critical view of safety prior
to transecting any structures. This is true of all laparoscopic
cholecystectomy, but especially true in this case, in which

Fig. 2: Dissection of the Calot’s triangle the patient’s anatomic configuration is not familiar. Some
surgeons may opt to selectively perform a cholangiogram
1
to delineate ductal anatomy. This operation need entire
important aspects of the management of gallstones in
patients with situs inversus that are worth highlighting. While dissection to be performed by left hand, and this may be
there is no evidence to suggest that gallstones are more or done easier by left hand surgeon. Though laparoscopic
less common in people with situs inversus, the presentation cholecystectomy in such patients is technically more
with left upper quadrant pain may delay the diagnosis of demanding, an experienced laparoscopic surgeon can
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symptomatic gallstones. In this case, the patient presented perform it safely.
with epigastric pain only and had no definite left upper Thus, situs inversus totalis does not appear to be
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quadrant pain. It has been noted in 30% of previous reported contraindication to laparoscopic cholecystectomy.
cases of acute cholecystitis in patients with situs inversus
that the pain was felt in the epigastrium alone and in 10% REFERENCES
the pain was localized to the right upper quadrant the 1. Dan Eisenberg Department of Surgery, Palo Alto VA Health
proposed explanation for this is that the central nervous Care System and Stanford School of Medicine, Palo Alto, CA,
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system may not share in the general transposition. The USA. Cholecystectomy in situs inversus totalis: A laparoscopic
first case of laparoscopic cholecystectomy in a patient with approach. International medical case reports journal, 27 October
2009.
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situs inversus was in 1991. In patients with situs inversus, 2. Shah AY, Patel BC, Panchal BA. Parth Surgical Hospital, Shashi
the mirror image anatomy poses difficulty in orientation Complex, Near Swaminarayan Avenue, Anjali Cinema Cross
during laparoscopic cholecystectomy. While there is no Road, Vasana, Ahmedabad - 380007, Gujarat, India.
evidence to suggest that there is an increased risk of bile Laparoscopic cholecystectomy in-patient with situs inversus.
duct injuries in patients with situs inversus, the orientation journal of minimal access surgery 2006;2(1),27-28.
and ergonomic challenges may result in an increased operative 3. Heather Rosen, Mikael Petrosyan, Rodney J Mason,
Cholecystitis in situs Inversus Totalis. Radiology case reports
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time. Our total operating time was 50 minutes. As the 2008;3(4).
unusual orientation while operating on a left-sided gallbladder 4. Sumihiro Kamitani, Yosihiro Tsutamoto, Kazuyoshi Hanasawa,
requires mental adaptability and manual dexterity to cope Tohru Tani. Laparoscopic cholecystectomy in situs inversus
with any evolving difficult or potentially dangerous totalis with “inferior” cystic artery: A case report. World J
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intraoperative situation. 5. Rao PG, Katariya RN, Sood S, Rao PLNG. Situs inversus totalis
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inversus should be performed by an experienced laparoscopic ovaries. J Postgrad Med 1977;23:89-90.

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