I had performed one case of situs inversus totalis. Male patient with cholecystitis and CBD stone. I had did preoperative ERCP and endoscopic sphincterotomy. After 4 weeks I did laparoscopic cholecystectomy with intraoperative cholangiogram. This was interesting. I can post the video.

I performed it once, and there were no problems. everything like ever. but right was left and vice versa, so I stood on the right side oft the patientalso postoperatively no problems.

Samuel E. Adjepong . UK

i have been fortunate to operate on two patients with situs inversus. one had open cholecystectomy and the other laparoscopic. it is like driving a car with the streering opposite to your usual hand drive. it is always interesting how the preoperative diagnosis was arrived at but the management is nothing special.

Do one in congenital ananomaly case no problem

lots reported in the literature

I also have performed laparosocpic cholecystectomy in situs inversus, in just one case. The anatomy was not normal, because the entry of the cystic duct into the common bile duct was from the right hand side (when you might have expected it to be from the left in this situation) so there seemed to be a degree of malrotation that went along with the situs inversus. Otherwise the case was uncomplicated and the patient recivered well

I've done two cases. I'm a right handed surgeon, and I perform cholecystectomies with three ports. In my point of view, I believe that the most difficult task, is to do the dissection with the left hand meanwhile the right hand is grasping and keeping traccion of the fundus of the gallblader.

Same, same but different and somewhat awkward. Other complete or incomplete malrotations in the GI-tract have to be considered so no accidental injury occurs due to this, especially if other procedures are added.

I have performed in one case and published a series reviewing 28 cases in 2008. You could refer to it

I did a laparoscopic cholecystectomy in situs inversus totalis. The operation was the same with miror position of the three trocars. Moreover I have done an open "right" hemi-colectomy in a patient with intestinal malrotation [Tech Coloproctol. 2010 Nov;14 Suppl 1:S65-6]

I have never had a patient with situs inversus totalis; however I am currently reviewing the literature on malformation, malrotation and anomalies/variations in the biliary anatomy. I would perfom the cholecystectomy with causion on the one hand because of the unusual "mirror view" but on the other hand more importantly because of the higher incidence of bile duct variations and anomalies in such cases. Therefor I would recommend to performing intraoperative cholangiography - as I always do - to visualize the biliary anatomy and avoid bile duct injury.

I have had the experience of two cases of gallbladder fundus malrotation. Although the Hartmann's pouch was on top of the bile duct, the liver bed was well under the left lobe of the liver. Both cases presented with more difficulties to achieve a clear anatomy after blunt dissection of the hilar structures. Also, in either case I used an anterograde dissection (from fundus down), started standing on the right side of the patient, and operated through the two most lateral port sites. Once the anatomy was clear, I switched my position to the left side of the patient an proceeded as usually, performing an intraoperative cholangiography to rule out any other biliary anatomical variants.

Biliary anatomical variants are more frequent than we usually expect, or have been reported, and could be a predisposing factor to a potentially catastrophic bile duct injury. The more experience you achieve in laparoscopic cholecystectomy the more you start recognizing them in your regular practice.

I haven't performed neither open or laparoscopic cholecystectomy on in-situ inversus gallbladder and tried to propagate research for conservative surgical conduct on gallbladder lesion by cholecysotstomy to minimise pos-cholcystectomy iatrogenia on some cases, my question to Antonio Garcia Ruiz, Gerwin Bernhardt & Norman Machado is, either or not considering Biliary anatomical variation do any of you performed a follow-up of this patients for dumping syndrome and osteo-arthropaty complaints, if so for how many years?

Dear Rasheed AO Shidi

Both subjects of gallbladder malrotation that I operated on 2 and 5 years ago respectively were followed on a regular schedule: 1 week, 1 month and 3 months after the laparoscopic cholecystectomy. Neither of them had any complications or irregular symptoms afterwards. However, I did not perform any special test to rule out fast gastric emptying nor ostheoarthropaty.

Thank you for the interesting question.

Dr. Garcia-Ruiz

I ,ve done two cases and escluding an headache for the anatomical situation i hai no problem. In these cases i think cholangiography must always be' performed considerino the particolare anatomical situation

Thanks for the comments.I feel surgeons should discuss such situations that they come across occasionally in their lifetime as most of the surgeons might not get a chance to operate in such an individual in their lifetime even once.Importance lies in the fact that other surgeons can get practical lessons learned through surgeons interactions so that they can apply them well in time to manage such situations.

I was involved in one case of Lap.Chole for situs inversus,

It was easily performed .What need ed is only to put the stack on the left side of the patient and the surgeon will operate of course from right side,

I don't think cholangiogram is necessary unless other difficulties are encountered such as difficult anatomy .

We have performed Laparoscopic cholecystectomy to a case in total situs inversus and this was published in a Turkısh Journal as a case report.

J Kartal TR 2012;23(2):91-94 doi: 10.5505/jkartaltr.2012.26121

Laparoscopic Cholecystectomy

in a Patient with Situs Inversus Totalis

Mustafa GİRGİN, Burhan Hakan KANAT, Refik AYTEN, Ziya ÇETİNKAYA

CASE REPORT

Summary

The use of laparoscopy in gallbladder surgery is widely accepted as the gold standard. Situs inversus totalis, which is seen at a rate of 1/10.000-50.000 rate, does not have contraindication for laparoscopic cholecystectomy, and thus this method should be more frequently applied. We present a case of laparoscopic cholecystectomy in a patient with situs inversus totalis is presented and the benefits of port placement during surgery were evaluated.

I have performed cholecystectomy on 2 patients with situs invertus. I simply used a standard 4 port technique, with the ports reversed on left side. Technically it is slightly more difficult because the 'usual' manoeuvres for traction and dissection are reversed but otherwise the procedure was identical

We did LapChole in a female patient with attack of biliary pancreatitis about 7 years ago. We used 4-port technique with mirrored positioning of the ports, which as I think now, is not the best solution. It was a very, very uncomfortable operation. Four months after operation she underwent ERCP and residual stone extraction from CBD and the endoscopist shared with me that he also had orientation and positioning difficulties. Finally in same lady (and same team) we did a pylorus-preserving pancreaticoduodenectomy two years later because of mass-forming chronic pancreatitis, causing untreatable pain. And the open operation was easily performed, and all the team feels much more comfortable during the open procedure, comparing to laparoscopic one. So the LapChole can be more demanding than open PD in situs inversus.

Thanks!!! Dr. Alexander, for exhibiting your precious experience in a reasonable time post-cholecystectomy follow-up, imagine the procedure in new-born children exposed to the risk of post-cholecystectomy complications earlier in their life-time, reason why both pediatric surgeons & others in laparoscopy, should strive for a conservative conduct on this issue.

I had performed laparoscopic cholecystectomy in a patient with situs inversus totalis and it has been published few years back. it was review of literature and has been cited about 18 times in last few years. i would suggest you should read it as all aspects including the difficulties encountered during the surgery has been covered. the article can be found in researchgate publication list of mine

I had performed LC two patients with situs inversus in my early stage of laparoscopic.

It`s not difficult in operation. The patients were get well soon.

I haven't come across patients with situs inversus but I did have a patient who had a gallbladder bed arising from the left lateral segment of the liver. However, the gallbladder was quite long and the fundus lied right of the bile duct "as usual".

This created much difficulty during laparsocpic cholecystectomy as traction on the gallbladder pulled down the left lobe, thus obscuring the view. The apparent "cystic duct" was also unusually wide.

The anomaly was only apparent after the gallbladder was dissected free from the liver bed and it was not picked up on pre-operative ultrasound and MRCP examination.

Interesingly, the patient's father was also said to have had a difficult cholecystectomy although the reason for that was not know to me.

A similar case published by ours might be useful

My video "Single port laparoscopic cholecystectomy in situs inversus totalis using the E.K. glove port" have been published by websurg recently.

It may be of some help to you.

http://www.websurg.com/MEDIA/?noheader=1&doi=vd01en3867

Yes, i have performed three cases of lap cholecystectomy for situs inversus, the only thing that you change the the location of instruments( tower on the left side of the patient and the surgeon on the right side). It works well

Pereira-Graterol, Freddy;Siso-Calderón, Luis

Consideraciones técnicas durante la colecistectomía laparoscópica en paciente con

situs inversus totalis

Cirugía y Cirujanos, Vol. 77, Núm. 2, marzo-abril, 2009, pp. 145-148

going to perform open cholecystectomy on a situs inversus totalis patient tomorrow. lets see how it goes. will keep posted.

All the best Dr. Ashish Saxena.........but why open???? any other problem with patient??

She is hypertensive with history of MI. Hence anasthetist advised against laparoscopic procedure.

yes, few cases by standing on the right side of the patient and the monitor on the left it went smooth.

"As an anecdote, we - with Dr. Fausto Dávila Ávila and Dr. Leopoldo Gutiérrez - during a course we carried out a culdolaparoscopy (TV NOTES) in Mexico using a closed circuit television. We found something unexpected, a left gallbladder (sinistroposition), and after a few minutes of delay to identify the appropriate structures, we established that we could successfully continue with the transvaginal approach." ElHospital