Laparoscopic Cholecystectomy in a Patient with Situs Inversus Totalis: Port Placement and Dissection Techniques

Patient: Female, 56-year-old Final Diagnosis: Acute cholecystitis Symptoms: Cholelithiasis Medication: — Clinical Procedure: Laparoscopic cholecystectomy Specialty: Surgery OBJECTIVE: Rare co-existance of disease or pathology BACKGROUND: Situs inversus is a rare congenital condition. Since 1991, more than 60 cases of laparoscopic cholecystectomy have been reported in patients with situs inversus. There are many different port placement techniques depending on the surgeon’s preference. The fact that some of the critical dissection is easier performed by the left hand poses technical difficulty for right-handed surgeons. CASE REPORT: A 56-year-old woman with known situs inversus totalis and extensive past surgical history presented with acute cholecystitis. A Veress needle was used to enter the abdomen at Palmer’s point. Visiport was used to place the first 5-mm port at the left mid-clavicular line. The dissection was performed in a mirror image to the usual dissection through the epigastric port. CONCLUSIONS: There have been several techniques described in the literature to facilitate the dissection in laparoscopic cholecystectomy in patients with situs inversus totalis. We argue that the first port should be placed at the midclavicular line with Visiport. The other ports should be placed in mirror image of the normally placed ports, including a 12-mm epigastric port, 5-mm or 11-mm paraumbilical port, and 5-mm port at the left anterior axillary line. For dissection, we argue that it is preferable to have 2 assistants with 1 retracting the gallbladder and the other holding the camera. This allows the primary surgeon to use the dominant hand during critical dissection in this unfamiliar anatomy.