Cholecystitis in patients with SIT is a rare clinical condition. In a report by Sato et al., 1802 patients underwent laparoscopic procedures consecutively, and the incidence of situs inversus was found to be 0.2%
7. Sporadic reports of LC in visceral situs inversus have appeared in the literature since 1992
8. The reports of SIT cases have been increasing as more surgeons perform more LC procedures.
SIT does not increase the incidence of gallbladder disease. However, physical examination of a patient with situs inversus can be misleading and cause clinical confusion. The presentation with left upper quadrant pain may delay the diagnosis of gallstones. Although most patients present with pain on the left side due to the peritoneal irritation, ten percent of patients with cholelithiasis on the left side present with right-sided abdominal pain. Thirty percent of such patients have epigastric pain9. Because the central nervous system may not share the general transposition, pain can be felt in such different places10. So, in patients with situs inversus to whom LC is planned, complete assessment of the patient is mandatory in order to avoid potential complications6.
In a literature review by Machado et al, 32 patients with SIT have been operated on laparoscopically due to gallbladder disease. Among them, 6 patients had acute cholecystitis, 3 had biliary colics, 1 had empyema, 3 had cholangitis, and 19 had chronic cholecystitis. Previous abdominal operation had been performed in only one patient11. In our case, the patient past-medical history also revealed previous multiple abdominal operations. So far, including our patient, a total number of only 2 SIT cases who had had previous abdominal operations have undergone LC. In another report, laparoscopic appendicectomy was also carried out in addition to cholecystectomy12.
We performed fundohilar dissection of the gallbladder. Although, in this case, retrograde dissection was necessitated due to inadequate visualization of the hilus of the gallbladder in intrahepatic localization, some reports advocate antegrade dissection as it provides better visualization of the anatomical structures13,14.
In summary, the value of laparoscopy in evaluation of patients with atypical abdominal pain has been well established and LC is the treatment of choice for symptomatic cholelithiasis. Laparoscopic approach should be the same for patients with SIT and this is supported by previous reports in the literature. This procedure in patients with SIT is, however, more difficult than usual due to the mirror-image anatomy especially for a right-handed surgeon. With modifications in the surgical team and equipment, the operation can be performed safely by a surgeon experienced in laparoscopy.
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