Minimal Invasive Treatment for patient with situs inversus totalis with diagnosis Biliary Pancreatitis

G Peralta, MD, E Ortiz, md, A Topete, Z Del Real, A Palomo, MD, Alex Rodriguez, MD. Hospital Metropolitano “Bernardo Sepulveda “.

Purpose: report and describe a safe approach to laparoscopic cholecystectomy and Intraoperative Cholangiography in patients with situs inversus totalis and biliary pancreatitis.

Case: 50-years old female with 1 year with history of abdominal pain who was diagnosed with biliary pancreatitis and situs inversus totalis during work-up for epigastric pain. Physical exam present with tenderness in left upper cuadrant. Laboratory tests showed: high lipase levels, Chest X-ray showed dextrocardia fig1. Ultrasound showed location of gallbladder on the left side of the body with gallstones. An abdominal computed tomography confirmed the situs inversus and showed inflammation of the pancreas with peripancreatic fluid fig2. Once the pancreatitis resolved, the patient was program for laparoscopic cholecystectomy, in which the patient was placed in the supine position with both the surgeon and camera-man on his right side and the assistant on the left side. Monitor placed near the head of the patient at the left side. Trocars were introduced in the left side of the patient’s abdomen. We also identified the cystic artery fig3. The clip was placed distally on the cystic duct. A small enterotomy was made in the cystic duct. There was good bile flow back. We placed the Cholangiocath without any difficulty and there was good flow without any leak. We then placed the patient back in supine position, shot a series of cholangiograms with the possibility of distal common bile duct stones noted, but good flow into the duodenum. The rest of the ductal system was intact without any defects fig4.
The duration of the operation was 53 minutes, which is slightly longer than our standard laparoscopic cholecystectomy. Nonetheless, the patient was discharged on the morning following surgery, which is comparable to other patients undergoing laparoscopic cholecystectomy.

Discussion: Situs inversus is a congenital condition. It can either be partial or total. This entity is considered to have a genetic predisposition that is autosomal recessive with the defect being localised on the long arm of chromosome 14.
There is no evidence that situs inversus predisposes to cholelithiasis, but it may be a cause of diagnostic confusion. Delay in the diagnosis was due to the left upper abdominal pain and unknown situs inversus. Internet search has revealed 37 reported cases of cholecystectomy in situs inversus including our case, but we don’t found biliary pancreatitis case.

We concluded that there is technical difficulty performing laparoscopic cholecystectomy in such patients. The dissection was quite safe and confirms the previous reports of safe laparoscopic cholecystectomy in situs inversus totalis despite the reversed anatomic relationships and other arterial anomaly. At least two thirds of surgeons are right handed. It is necessary for these surgeons, and their assistants, to modify their usual surgical technique to comfortably and safely carry out the procedure. Rather than the clumsy crossing of hands to retract on Hartmann’s pouch for dissection of Calot’s triangle, we suggest that retraction on Hartmann’s pouch may be carried out by the assistant, thus allowing the surgeon to operate in a more ergodynamic fashion.

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