A 35 year old female presented with recent intermittent pain in the left hypochondrium occasionally radiating to the back and dyspepsia often associated with episodes of vomiting. She reported similar episodes in the last 2 years relieved on intravenous antacids and analgesics. There was no history of fever, jaundice, altered bladder or bowel habits, abdominal distension or weight loss. She underwent open tubal ligation at the age of 27 years and had an uneventful recovery following that. She had no other ailments or symptoms.
On clinical examination, there was no jaundice or fever. The abdominal examination revealed mild tenderness in the left hypochondrium, a linear scar in the midline in the infra-umbilical region 8 cm below the umbilicus and the rest of the abdominal examination was unremarkable. The apex beat was present in the fifth intercostal space on the right mid clavicular line.
The patient's blood investigations revealed normal complete blood count, liver and kidney function tests, serum electrolytes, blood glucose. An ultrasonography of the abdomen  was performed which showed the following:
1. Liver and gall bladder on the left side [a], gall bladder lumen filled with multiple subcentimetric calculi with posterior acoustic shadowing.
2. Common Bile Duct diameter 5 mm, portal vein normal.
3. Spleen on the right side [b], Inferior vena cava on the left side and aorta on the right side [c].
Ultrasonography abdomen-left sided liver & gall bladder (a), right sided spleen (b), left sided IVC and right sided aorta (c).
The chest radiograph of the patient showed heart shadow on the right side (dextrocardia) and the left hemi diaphragm to be raised as compared to the right side .
Chest radiograph showing dextrocardia.
The diagnosis of cholelithiasis with situs inversus totalis was established and decision to perform a laparoscopic cholecystectomy was taken after admitting the patient electively.
In order to conduct the surgery, the theatre equipment including the monitor, CO2 insufflator and diathermy were positioned in the mirror image of their normal position on the left side of the patient. The patient was positioned in the reverse Trendelenberg position with the right side slightly inclined up. The difficulty of even creating pneumoperitoneum from the right side by a right handed surgeon was experienced, so it was created comfortably from the left side as is done conventionally as the vision component was not involved. The first 10 mm port was inserted through the infra umbilical incision and confirmation of the diagnosis of situs inversus was done from the left side only .
Liver and gall bladder in the left hypochondrium.
Subsequently the position of the surgical team was: the primary surgeon and the first assistant on the right side of the patient and the second assistant on the left side. Another 10 mm port was placed 5 cm below the xiphoid process just to the left of the midline. The other two 5 mm ports were inserted in the usual way but on the left side . A toothed grasper was inserted through the port 4 and was used to retract the fundus of the gall bladder. Being a right handed surgeon, the primary challenge was to retract the Hartmann's pouch while dissecting the Calot's triangle which led to crossing of the hands .
Port positions-mirror image.
Post operative sutured port sites.
This difficulty was overcome by allowing the first assistant to retract the Hartmann's pouch throughout the surgery while the main surgeon dissected the Calot's triangle using his right hand from the epigastric port with convenience. The cystic duct was noticed to be short and wide. It was dissected separately from the cystic artery and both separately clipped and divided via the epigastric port only. It was again found to be difficult to apply clips as the angle of the clip applicator did not fit along the direction of the cystic artery. The gall bladder was dissected out from the gall bladder fossa using the hook diathermy via the epigastric port with the first assistant maintaining traction on the gall bladder. At the time of retrieval of the gall bladder, the calculi were removed using the ovum forceps and the organ extracted out via the subxiphoid epigastric port.
The duration of the surgery was found to be 95 min which was longer than the conventional laparoscopic cholecystectomy which can be explained by the modification in the ergonomics made to adjust to the mirror image anatomy. The post operative period was uneventful and the patient was discharged the following day.