Fluorescence cholangiography during laparoscopic cholecystectomy in a patient with situs inversus totalis: a case report and literature review
© The Author(s). 2017
Received: 8 February 2017
Accepted: 11 April 2017
Published: 20 April 2017
Situs inversus totalis is a rare autosomal disorder in which the patient’s affected visceral organs are a perfect mirror image of their normal positions. Surgery in these patients is technically challenging. Minimally invasive surgery such as laparoscopic cholecystectomy is the standard treatment for symptomatic cholelithiasis, but it can be difficult to perform. Laparoscopic cholecystectomy in patients with situs inversus totalis may be even more technically challenging. Fluorescence cholangiography is a new innovation in the field of navigation surgery. This procedure is safe and easy to perform, its findings are easy to interpret, and it does not require a learning curve or radiographs. It can be used in real time during surgery to identify extrahepatic biliary structures.
We herein report a case of situs inversus totalis in a Thai patient with a history of biliary pancreatitis. He underwent laparoscopic cholecystectomy with intraoperative fluorescence cholangiography. The operation was successfully completed without complications. To the best of our knowledge, this is the first case report of the use of fluorescence cholangiography during laparoscopic cholecystectomy in a patient with situs inversus.
Fluorescence cholangiographyis a new navigational surgical technique with which to identify extrahepatic biliary structures. It can be used as an adjunct technique during laparoscopic cholecystectomy to avoid biliary tract injury in difficult cases.
KeywordsSitus inversus Situs inversus totalis Laparoscopic cholecystectomy Fluorescence cholangiography Cholelithiasis
Situs inversus totalis (SIT) is a rare autosomal recessive disorder with an incidence of 1 in 5000 to 20,000 live births. The anatomy of patients with SIT is a perfect mirror image of the normal positions of their visceral organs .
Surgery in patients with SIT is technically challenging. Minimally invasive surgery such as laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic cholelithiasis and may be difficult to perform. However, LC in patients with SIT may be even more technically challenging [2–6]. Although many previous case reports have described the performance of LC in patients with situs inversus no standard technique has been established for these patients.
Optical or real-time surgery is being increasingly reported in the literature [7, 8]. One technique used in optical surgery is fluorescence cholangiography (FC) . This method involves the administration of indocyanine green (ICG) by intravenous injection 30 min before surgery. ICG is taken up by the liver then excreted exclusively in the bile. The excitation of protein-bound ICG by near-infrared light causes it to fluoresce, thereby delineating components of the biliary system for the surgeon. Fluorescence and imaging is achieved through a system comprising a small control unit, a charge-coupled device camera, a xenon light source, and a 10-mm laparoscope containing specially coated lenses that transmit near-infrared light. FC is a feasible, low-cost, expeditious, useful, and effective imaging modality. Additionally, it is safe and easy to perform, its findings are easy to interpret, and it does not require a learning curve or radiographs. FC can be used during surgery to identify extrahepatic biliary structures [10, 11].
We herein report a case of cholelithiasis in a Thai patient with SIT who presented with a history of biliary pancreatitis. FC was performed during LC. To the best of our knowledge, this is the first such case reported in the literature.
A 32-year-old man was referred to our hospital for further treatment. He had a known history of SIT. He had been admitted to the previous hospital with acute abdominal pain, and biliary pancreatitis was diagnosed. Ultrasonography showed multiple small gallstones. He was treated conservatively until clinical improvement was noted. After discharge, he was referred to our hospital. In our outpatient clinic, he was well with no fever, abdominal pain, or jaundice.
Additional file 1: Laparoscopic cholecystectomy in situs inversus totalis patient with using fluorescence cholangiography during the operation.
LC is the standard treatment for symptomatic cholelithiasis. In patients with SIT, however, LC is often technically demanding. Because of the unusual orientation, especially for right-handed surgeons, bile duct injury may easily occur . Many previous reports have described LC in patients with SIT, but no standard techniques have been established for these patients [2–6].
Since Campos and Sipes  first reported LC in a patient with SIT in 1991, more than 50 cases of LC in patients with SIT have been reported without complications, even in patients with acute cholecystitis [2–4, 14, 15]. Thus, LC is not contraindicated in patients with SIT. However, such patients are at higher risk of complications because the mirror image of the anatomy is an unusual orientation . Most previous reports have concluded that LC in patients with SIT is technically challenging and requires surgeons who are experienced in laparoscopic procedures and hepatobiliary surgery [3–6].
The most common surgical technique used by right-handed surgeons is the four-port technique with an incision created as a mirror image of the conventional incision [6, 17, 18]. The surgeon stands on the right side of the patient, the first assistant stands on the left side, and the camera assistant stands on the right side next to the surgeon. Left-handed instruments are used to grasp Hartmann’s pouch, and the right hand is used in the mid-clavicular port for dissection [3, 18].
FC is a recent innovation in optical surgery. ICG is intravenously injected about 15 to 30 min before the operation, and a special laparoscope containing specially coated lenses that transmit near-infrared light is used. FC is a feasible, low-cost, expeditious, useful, and effective imaging modality. It is safe and easy to perform, and its results are easy to interpret. Many previous reports have described the use of FC during LC to visualize the extrahepatic biliary anatomy and help to avoid bile duct injury [9–11]. This technique has been proven feasible, repeatable, and inexpensive . The critical point in performing LC in patients with SIT is similar to that in patients without SIT; namely, that the critical view of safety must be identified [16, 19, 20]. In the present case, FC was used as a guidance technique with which to identify the biliary tree during the operation, especially at Calot’s triangle. This allowed for identification of the critical view of safety, making the operation less difficult. In such cases of difficult LC, as in patients with SIT, FC would be very helpful for surgeons to delineate the extrahepatic biliary tract. Even for less experienced surgeons, the use of FC guidance during careful dissection of Calot’s triangle could help to avoid biliary injury.
LC in patients with SIT is a technically challenging procedure that requires an experienced surgeon. FC is a new navigational surgery technique that can be used to examine the extrahepatic biliary tree and serve as an adjunct during LC in difficult cases, helping to avoid biliary tract injury.
Situs inversus totalis
The authors thank KOSIN Medical Supply Co., Ltd. for contributing the fluorescence equipment.
The authors declare that they received no funding.
Availability of data and materials
The data are available from the corresponding author upon reasonable request.
RN collected the patient’s clinical data, analyzed the data, and majorly contributed to the writing of the manuscript; TP wrote the manuscript. Both authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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Written informed consent was obtained from the patient for publication of this case report.
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- Roy A, Crawford JM, Finegold MJ. Inherited metabolic and developmental disorders of the pediatric and adult liver. In: Odze RD, Goldblum JR, editors. Surgical Pathology of the GI Tract, Liver, Biliary Tract and Pancreas, Third Edition. Philadelphia: Elsevier; 2015. P. 1475-1538.
- Ahmed Z, Khan SA, Chhabra S, Yadav R, Kumar N, Vij V, Saxena D, Talera D, Kankaria J, Gupta S, Bugalia RP, Goyal A, Yadav BL, Jenaw RK. Our experience with surgery in situs inversus: open peptic perforation repair and laparoscopic cholecystectomy in 1 patient and 3 patients respectively. Int J Surg Case Rep. 2016;29:34–8.View ArticlePubMedPubMed CentralGoogle Scholar
- Phothong N, Akaraviputh T, Chinswangwatanakul V, Trakarnsanga A. Simplified technique of laparoscopic cholecystectomy in a patient with situs inversus: a case report and review of techniques. BMC Surg. 2015. doi:10.1186/s12893-015-0012-6.PubMedPubMed CentralGoogle Scholar
- Fang JF, Zheng ZH, Wei B, Chen TF, Lei PR, Huang JL, Huang LJ, Wei HB. Laparoscopic resection for rectal cancer and cholecystectomy for patient withsitus inversus totalis. J Minim Access Surg. 2015;11:210–2.View ArticlePubMedPubMed CentralGoogle Scholar
- Aydin U, Unalp O, Yazici P, Gurcu B, Sozbilen M, Coker A. Laparoscopic cholecystectomy in a patient with situs inversus totalis. World J Gastroenterol. 2006;12:7717–9.View ArticlePubMedPubMed CentralGoogle Scholar
- McKay D, Blake G. Laparoscopic cholecystectomy in situs inversus totalis: a case report. BMC Surg. 2005. doi:10.1186/1471-2482-5-5.PubMedPubMed CentralGoogle Scholar
- Rosenthal EL, Warram JM, Bland KI, Zinn KR. The status of contemporary image-guided modalities in oncologic surgery. Ann Surg. 2014;261:46–55.View ArticleGoogle Scholar
- De Boer E, Harlaar NJ, Taruttis A, Nagengast WB, Rosenthal EL, Ntziachristos V, van Dam GM. Optical innovations in surgery. Br J Surg. 2015;102:e56–72.View ArticlePubMedGoogle Scholar
- Ishizawa T, Bandai Y, Ijichi M, Kaneko J, Hasegawa K, Kokudo N. Fluorescent cholangiography illuminating the biliary tree during laparoscopic cholecystectomy. Br J Surg. 2010;97:1396–77.View ArticleGoogle Scholar
- Kono Y, Ishizawa T, Tani K, Harada N, Kaneko J, Saiura A, Bandai Y, Kokudo N. Techniques of fluorescence cholangiography during laparoscopic cholecystectomy for better delineation of the bile duct anatomy. Medicine (Baltimore). 2015;94:e1005.View ArticleGoogle Scholar
- Pesce A, Piccolo G, La Greca G, Puleo S. Utility of fluorescent cholangiography during laparoscopic cholecystectomy: a systematic review. World J Gastroenterol. 2015;21:7877–83.View ArticlePubMedPubMed CentralGoogle Scholar
- Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunger JG. Causes and prevention of laparoscopic bile duct injuries analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237:460–9.PubMedPubMed CentralGoogle Scholar
- Campos L, Sipes E. Laparoscopic cholecystectomy in a 39-year-old female with situs inversus. J Laparoendosc Surg. 1991;1:123–5.View ArticlePubMedGoogle Scholar
- Alsabek MB, Arafat S, Aldirani A. A case report of laparoscopic cholecystectomy in situs inversus totalis: Technique and anatomical variation. Int J Surg Case Rep. 2016;28:124–6.View ArticlePubMedPubMed CentralGoogle Scholar
- Reddy A, Paramasivam S, Alexander N. Abhilash, Ravisankar V, Thillai M. Management of a patient with situs inversus totalis with acute cholecystitis and common bile duct stones: a case report. Int J Surg Case Rep. 2014;5:821–3.View ArticlePubMedPubMed CentralGoogle Scholar
- Polychronidis A, Karayiannakis A, Botaitis S, Perente S, Simopoulos C. Laparoscopic cholecystectomy in a patient with situs inversus totalis and previous abdominal surgery. Surg Endosc. 2002;16:1110.View ArticlePubMedGoogle Scholar
- Pahwa HS, Kumar A, Srivastava R. Laparoscopic cholecystectomy in situs inversus: points of technique. BMJ Case Rep. 2012. doi:10.1136/bcr-2012-006170.Google Scholar
- Arya SV, Das A, Singh S, Kalwaniya DS, Sharma A, Thukral BB. Technical difficulties and its remedies in laparoscopic cholecystectomy in situs inversus totalis: a rare case report. Int J Surg Case Rep. 2013;4:727–30.View ArticlePubMedPubMed CentralGoogle Scholar
- Salama IA, Abdullah MH, Houseni M. Laparoscopic cholecystectomy in situs inversus totalis: Feasibility and review of literature. Int J Surg Case Rep. 2013;4:711–5.View ArticlePubMedPubMed CentralGoogle Scholar
- Machado NO, Chopra P. Laparoscopic cholecystectomy in a patient with situs inversus totalis: feasibility and technical difficulties. JSLS. 2006;10:386–91.PubMedPubMed CentralGoogle Scholar