Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 67, Num. 4, 2005, pp. 226-227

Indian Journal of Surgery, Vol. 67, No. 4, July-August, 2005, pp. 226-227

Letter To Editor

Laparoscopic cholecystectomy in a patient with situs inversus

Das S, Bhattacharjee PK, Bandyopadhyay S, Choudhuri, T, Goswami P, Goel N

Department of Surgery, R. G. Kar Medical College & Hospital, Kolkata
Correspondence Address:Das, Department of Surgery, R. G. Kar Medical College and Hospital, Kshudiram Bose Sarani, Kolkata - 700 004, West Bengal,

Code Number: is05073

Dear Editor,

Laparoscopic cholecystectomy has become the gold standard for treatment of calculous cholecystitis. We describe a case of laparoscopic cholecystectomy performed in a patient with Situs Inversus.

A 40-year-old lady, presented with recurrent pain epigastrium; initially the radiation was nonspecific but subsequently pain was mainly in the left upper quadrant. Physical examination revealed only tenderness in the left hypochondrium and dextrocardia. Routine investigations revealed no abnormality except dextrocardia confirmed on chest X-ray.

Ultrasonography and CT-scanning revealed the diagnosis of situs inversus along with calculous cholecystitis. Laparoscopic cholecystectomy was done, to enable the patient to get the accepted benefits of laparoscopic surgery. Accordingly, the following changes were made in the OT-setup and the operation:

• The surgeon and the assistant at the telescope stood on the right of the patient and the other assistant on the left
• The monitor was placed behind the left shoulder of the patient.
• The umbilical and substernal ports were placed as usual but the telescope had to be introduced towards the left upper quadrant; the trocar of the substernal port had to be angled towards the left, to the left of the left-sided falciform ligament. The two other ports were also introduced as usual except that these were on the left side of the abdomen and not the right.

The following difficulties were encountered:

• Adhesiolysis was difficult due to fear of inadvertent damage to the unusual anatomy.
• The gall-bladder was having to be held by the right hand by the grasper while dissection was being carried out by the left hand. At times the instruments had to be reintroduced through opposite ports to allow dissection to proceed by the more convenient hand!
• The CBD was to the right of the Calot′s triangle and not the left and this required constant mental concentration and reorientation.

Situs inversus is a rare, autosomal recessive condition with an incidence of 1/10.000;[1] clinical diagnosis is problematic but modern imaging procedures such as USG usually suffice to diagnose gallbladder disease and as in our case, also reveal the transposition. Laparoscopic cholecystectomy has been rarely reported in situs inversus (total 22 reports found on Pubmed Search) with the first case being reported in 1992[2], Indian references being few[3],[4]. All authors have commented on the rarity of the condition[4],[5] and have stressed that the procedure requires mental reorientation to the altered spatial relationships of the structures and necessitates reorientation of hand-eye coordination too.

In conclusion laparoscopic cholecystectomy in a patient with situs inversus is difficult due to the unfamiliar spatial orientation of structures. The operation requires mental reorientation and readjustment of the usual hand-eye coordination. However, despite all this, it is still quite feasible and safe, and should be offered to these otherwise normal patients.

ACKNOWLEDGEMENT

0Dr. Kamalesh Majumdar, Radiologist, for his help in preparing the report and Dr. Soumaparna Kundu, Anaesthetist, for her help during the operative procedure.

References

Copyright 2005 - Indian Journal of Surgery