Laparoscopic cholecystectomy with common bile duct exploration for choledocholithiasis in a patient with situs inversus totalis - Case report and review of literature

Abstract

Introduction and importance

Laparoscopic common bile duct (CBD) exploration with cholecystectomy in patients with situs inversus totalis (SIT) is technically demanding and warrants comprehensive knowledge of the mirror image anatomy along with laparoscopic orientation of the left upper quadrant.

Case presentation

In this case report, we present a female patient who presented with pain in the left hypochondrium, yellowish discoloration of the eyes since 2 months. She was evaluated, diagnosed to be a case of SIT with cholelithiasis and choledocholithiasis in cholangitis and endoscopic attempts for stone clearance failed. She subsequently underwent laparoscopic common bile duct exploration (LCBDE) with cholecystectomy. Per-operative, cystic duct was short and a choledochoscope was utilized for bile duct clearance.

Clinical discussion

Laparoscopic surgery in patients with SIT is complex, technically challenging and requires a in depth knowledge of remodeled anatomy. We noted a change in the relation of portal vein with CBD as in the portal vein was postero-lateral to bile duct rather than being completely posterior. The key here is to stay close to the common bile duct which can avoid confusion and inadvertent injury to vital structures in the hepato-duodenal ligament.

Conclusion

Laparoscopic cholecystectomy and CBD exploration in situs inversus is extremely challenging and the surgeon should be aware of the ergonomics and practice to operate laparoscopically with the opposite hand I.e the non-dominant hand in right-handed surgeon. Thus, laparoscopic cholecystectomy with LCBDE in situs inversus totalis is safe and feasible but demands technical difficulties.

Highlights

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  Surgical management of biliary tract stones in patients with Situs inversus totalis (SIT) is technically complex.

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  A hepato-biliary surgeon should be aware of the altered anatomy since endoscopic management in these patient of SIT with choledocholithiasis often fails due to altered anatomy of duodenum.

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  This report highlights the challenges faced during laparoscopy in these patients and how to overcome them.