Situs Inversus Totalis: Operating on the Mirror Image

Abstract

Situs inversus totalis is a rare congenital anomaly where the internal organs are located in the reverse position, thus forming a mirror image of the normal distribution of organs in our body, i.e. situs solitus. Laparoscopic cholecystectomy in patients with situs inversus poses a challenge for the surgeon for its anatomical variation and reverse ergonomics. Herein we report the case of a 27-year old lady who presented with pain over the left hypochondrium often radiating to left scapular region associated with flatulence and dyspepsia. Ultrasonography revealed gall stone disease with situs inversus totalis, which was subsequently confirmed with CT scan of abdomen and echocardiography. Laparoscopic cholecystectomy was performed safely with the ports placed on the left side. Patients with situs inversus may harbour other serious cardiorespiratory or intra-abdominal anomalies including anomalies of the extra-hepatic biliary tree. Performing laparoscopic cholecystectomy in them is difficult because of anatomical mirror imaging and ergonomical challenges. Prior diagnosis of the condition, proper workup and meticulous dissection at the Calot’s tringle by an experienced laparoscopic surgeon can end up with a safe surgical outcome. Safe laparoscopic cholecystectomy is feasible in patients with situs inversus provided the condition is diagnosed including the anatomical variations prior hand and the surgery is performed by an experienced laparoscopic surgeon. Moreover, every laparoscopic surgeon must be well conversant with the use of his/her left hand as well. Nowadays, robotic minimal access surgery can be a better solution to this problem.