A thirty two year old female was admitted with a three hour history of epigastric pain radiating into her back in keeping with biliary colic. She had vomited a number of times. In the previous week she had two episodes of a similar nature.
On examination there was no jaundice or pyrexia. The apex beat was in the right fifth intercostal space, midclavicular line. She had epigastric tenderness but was not tender in the right or left upper quadrants. Her white cell count and amylase level was normal but her C-reactive protein level (CRP) was elevated at 290 mg/L. An electrocardiograph showed right axis deviation and right ventricular hypertrophy, in keeping with dextrocardia.
An ultrasound scan of the upper abdomen identified the gallbladder, which contained stones, in the left upper quadrant. The spleen was visualised in the right upper quadrant. There was no evidence of common bile duct or intrahepatic duct dilatation. Chest X-Ray confirmed the clinical and electrocardiograph diagnosis of dextrocardia.
The diagnosis of acute cholecystitis and situs inversus was made. The patient settled clinically over two to three days and was discharged home to be admitted electively for laparoscopic cholecystectomy.
In order to conduct the laparoscopic cholecystectomy all theatre equipment including diathermy, monitors and CO2 insufflator were positioned in the mirror image of their normal position. The surgical team also changed sides with the primary surgeon and first assistant on the patients right and the second assistant on the left. The ports were inserted in the usual way but on the left side. At laparoscopy the entirety of the abdominal contents were indeed reversed.
The main difficulty encountered was that the primary surgeon, who was right handed, would have had to cross hands to retract on Hartmann's pouch while dissecting Calot's triangle. We overcame this difficulty by allowing the first assistant to retract on Hartmann's pouch, while the primary surgeon dissected Calot's triangle using his right hand via the epigastric port without hindrance. The common bile duct and cystic duct were identified, as was the cystic artery, which lay anterior to the cystic duct. The surgery proceeded without incident and the patient recovered and was discharged the next day.