Our experience with surgery in situs inversus: Open peptic perforation repair and laparoscopic cholecystectomy in 1 patient and 3 patients respectively

Abstract

Introduction: Situs inversus is a rare autosomal recessive condition associated with complete transposition of abdominal+/- thoracic organs. Surgical diagnosis and surgical procedures in patients with situs inversus is tricky because of the mirror image anatomy of intra-abdominal organs.

Materials and methods: A retrospective analysis of 2152 and 1497 patients who underwent laparoscopic cholecystectomy and open peptic perforation repair respectively from June 2014-June 2016 was done. 1 patient and 3 patients with situs inversus underwent open peptic perforation repair and laparoscopic cholecystectomy respectively. A 10mm left para-median port 5cm caudally from xiphoid was used for grasping the infundibulum. Two 5mm ports placed 10cm caudally from costal margin in the mid-clavicular and anterior axillary line were used for dissecting and retracting fundus respectively. A 10mm supra-umbilical camera port was used.

Results: A 40year male with situs inversus totalis underwent open peptic perforation repair. Laparoscopic cholecystectomy was done in 3 female patients with situs inversus aged 33-46year (mean 41year). Mean operative time for laparoscopic cholecystectomy was 59min (39-93). There were no intraoperative or post-operative complications. Histopathology revealed chronic inflammation in peptic perforation and cholecystitis.

Conclusion: Perforation peritonitis in situs inversus can cause diagnostic confusion with free gas under the left hemi diaphragm. Laparoscopic cholecystectomy in situs inversus is ergonomically inconvenient and technically difficult for right handed surgeons. We describe an ergonomically convenient port placement for right handed surgeons in situs inversus.

Keywords: Laparoscopic cholecystectomy; Omentopexy; Perforation peritonitis; Situs inversus.

Fig. 1

in Patient 1 (A) Chest X-ray erect PA view showing dextrocardia with fudus air shadow of right side with free intra-peritoneal air under left hemidiaphragm. (B) Liver and gall bladder (white arrow) on the left side. (C) A 2.5 cm × 0.5 cm antral perforation on anterior wall of stomach. (D) Appendix on left side.

Fig. 2

in Patient 3 (A) Grasper from the left paramedian port being used to retract the infundibulum and the left mid clavicular line port being used to dissect the Calot’s traingle. (B) 1. Left paramedian port 5 cm below the xiphoid for grasping the infundibulum. 2. Left mid-clavicular line port 10 cm below costal margin for dissecting the Calot’s triangle. 3. Left anterior axillary line port 10 cm below costal margin for retracting the fundus. 4. Supraumbilical camera port.

Fig. 3

in Patient 4 (A) Gall bladder and liver on left side. (B) A completely dissected Calot's triangle with the cystic duct clipped.

Fig. 4

in Patient 2 showing ongoing dissection of the Calot's triangle.