# Laparoscopic Cholecystectomy for Severe  Acute Cholecystitis in a Patient with Situs Inversus Totalis  and Posterior  Cystic Artery

Authors: Theodoros E. Pavlidis; Kyriakos Psarras; Apostolos Triantafyllou; Georgios N. Marakis; Athanasios K. Sakantamis
Journal: Diagnostic and Therapeutic Endoscopy
 (2008)

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## Abstract

Situs inversus totalis is an inherited condition characterized
by a mirror-image transposition of thoracic and abdominal organs. It often coexists
with other anatomical variations. Transposition of the organs imposes special demands
on the diagnostic and surgical skills of the surgeon. We report a case of a 34-year-old
female patient presented with left upper quadrant pain, signs of acute abdomen, and
unknown situs inversus totalis. Severe acute cholecystitis was diagnosed,
and an uneventful laparoscopic cholecystectomy was performed. A posterior cystic
artery was identified and ligated. Laparoscopic cholecystectomy is feasible in patients
with severe acute calculus cholecystitis and situs inversus totalis; however,
the surgeon should be alert of possible anatomic variations.


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## Body

## 1. Introduction

Situs viscerum inversus totalis or total transposition of thoracic and abdominal organs is a rare congenital disorder, inherited by an autosomal recessive gene. It appears
with an incidence ranging between 1 : 5000 and 1 : 20000 according to the region
[1]. It may pose several technical difficulties during operative procedures,
especially during laparoscopic operations. The mirror image of laparoscopic
view creates unfamiliarity for the surgeon and his usual maneuvers.
Additionally, all instrument design is for right-handed surgeons. More than
twenty cases of laparoscopic cholecystectomy in patients with situs inversus
totalis have been reported up to now including a few other laparoscopic
procedures, that is, common bile duct exploration, Nissen fundoplication, and
appendectomy [1–5].Severe acute cholecystitis already
requires caution and meticulous maneuvers during laparoscopic cholecystectomy,
because the anatomy in Callot’s triangle is rather obscure due to inflammation,
fibrosis, and adhesions. The risk of injury, mainly of the common bile duct, is
increased. Ifsitus inversus totalis coexists, the technical
difficulties are exacerbated. Furthermore, the increased possibility of other
anatomic variations [2] makes the operation further unfamiliar and increases
the risk of complications.We report a case of laparoscopic
cholecystectomy for severe acute calculus cholecystitis, in a patient withsitus
inversus totalis and posterior cystic artery, highlighting the condition
and the operating difficulties.


## 2. Case Report

A 34-year-old woman was admitted in
emergency with left upper quadrant pain which started suddenly three days ago
after a heavy meal, fever (38.5°C), nausea, and fatigue. Anamnesis was free of any past
illnesses. Clinically, abdominal tenderness, guarding, and rebound tenderness
were found in the left upper quadrant; the heart sounds were normal, but
audible on the opposite side of the chest. Apart of leucocytosis (19.500/mm3),
all other laboratory tests were normal. The preoperative electrocardiogram and
chest X-rays showed signs of dextrocardia. On ultrasound, the right lobe of the
liver and gallbladder were found on the left side; the spleen was visualized on
the right. The gallbladder was seen distended, with signs of inflammation,
containing several gallstones. Common bile duct was of normal diameter. A CT scan confirmed the diagnosis of acute cholecystitis and situs inversus totalis.Laparoscopic cholecystectomy was
performed with the  4-trocar technique, according to the ‘‘American’’ variable.
The theatre equipment and the surgical team were positioned reverse.  The first trocar (10 mm) with a balloon was
inserted under direct vision using the open technique (Hasson’s method) in the
subumbilical region. The working trocar (10 mm) was inserted in the usual subxiphoid
region and directed to the left of the round ligament; the two grasping trocars
(5 mm)
were inserted in the usual way but on the left side (middle subcostal and
lateral). Pneumoperitoneum was maintained stable at 12 mm Hg. An initial
laparoscopy inspected the reversed position of all intraperitoneal viscera. The
gallbladder was totally covered by great omentum.  After freeing the attachments, the fundus and
the upper half of the gallbladder appeared distended with signs of severe
inflammation (see Figure1). Grasping was not possible, therefore an evacuative
paracentesis was necessary. Hard adhesions were obscuring the anatomy in Callot’s
triangle.  Meticulous dissection ensured
complete freeing and definition of the course of both cystic duct and cystic
artery (see Figure 2). The former was on the left. The latter was on the right,
bifurcating into two branches: an anterior cystic branch running to the cystic
duct and Hartmann’s pouch and a posterior cystic branch running to the inferior
surface of the gallbladder. The gallbladder was partially intrahepatic; its
dissection from the liver bed was difficult but uneventful.  A drain was placed for 24 hours. The
procedure lasted 90 minutes. The gallbladder contained four large stones 2 cm in diameter. Intravenous
antibiotic treatment was administered for 48 hours. The patient had an
uneventful postoperative course and was discharged on the third day in a nicecondition.Figure 1
Laparoscopic view of the distended, severely inflamed gallbladder (GB) before evacuative paracentesis. F: fundus, FL: falciform ligament, D: duodenum, RL: right liver lobe, GO: greater omentum.Figure 2
Laparoscopic view of
Callot’s triangle after meticulous
dissection showing the cystic duct (CD), the cystic artery (CA), the posterior
cystic artery (PCA) running to the inferior surface of the gallbladder (GB), and the anterior
cystic artery (ACA) running to the Hartman’s pouch (HP). RL: right liver lobe.


## 3. Discussion

Situs inversus totalis may affect the intra-abdominal
viscera as well as the intrathoracic organs [1]. It may be associated with many
other anatomical variations, more often heart malformations, Kartagener’s
syndrome (coexistence with bronchiectasis and sinusitis), liver lobe
hypoplasia, biliary atresia in infants, vascular anomalies, and others [1, 2, 6–9]. In a patient with left upper
quadrant symptoms, thiscondition should be kept in mind. Physical examination,electrocardiogram, chest X-rays, and simple abdominal imaging (US, CT) can
direct and confirm the diagnosis. CT imaging is an easy examination to quickly
reveal anyserious malformations preoperatively, even in the case of an emergency operation.  If the patient’s
situation permits, it would be very useful to perform a magnetic resonance
cholangio-pancreatography (MRCP) or endoscopic retrograde
cholangio-pancreatography (ERCP) in order to reveal the exact anatomy of the
biliary tract [2].There have been several reports of
laparoscopic cholecystectomy for cholelithiasis insitus inversus totalis [1–5, 10, 11, 12], and a few others for acute cholecystitis [2, 13]. The encountered
difficulties have been well highlighted [1, 10–12]. Briefly, theatre equipment
and surgical team must bepositioned on the opposite side than usual (mirror
image).  The surgeon should keep in mind
the mirror image of the anatomy, and he should adjust technique and movements.
Before clipping, meticulous dissection and complete clearance of cystic duct
and cystic artery from other tissues represent an essential step for a safe procedure. An intraoperative cholangiogram
could be very helpful in case of obscure biliary and cystic duct anatomy
especially when a preoperative investigation of the biliary tree was not
performed [14]. Undoubtedly, the condition needs some extra time to be spent
for a safe laparoscopic cholecystectomy. The role of the first assistant for
appropriate retraction on Hartmann’s pouch or other elements to facilitate the
surgeon’s dissecting maneuvers by his right hand is also very important.Vascular anomalies of the coeliac
trunk and liver are very common in individuals withsitus inversus [8, 9]. The presence of additional cystic artery branches such as  a posterior
branch as happened in this case, or an inferior branch in another report [2]
may cause unwilling hemorrhage and confusion.
Where possible the performance of an abdominal angiography could solve
the problem as other investigators have also pointed out [2].  However, this is not always feasible, mainly
due to the patient’s condition and in such cases meticulous dissection is the
only way for a safe procedure.In conclusion, laparoscopic
cholecystectomy for severe acute calculus cholecystitis in a patient withsitus
inversus totalis and posterior cystic artery is feasible and safe, although
technically more demanding. Since the cases treated laparoscopically will be
increasing in the future, surgeons should be able to recognize reversed
anatomical relationships and coexistence of other anomalies.



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*Source: 465272-2008-05-07.xml*