Methods (Differential Diagnosis, Investigations and Treatment)
With the possible differential diagnosis of gastritis and biliary colic, the following investigations were done. Her laboratory investigations showed normal white blood cell counts of 9800 cells per cubic millimeters and liver function test was also found to be normal. Chest X-Ray (Figure 1) revealed dextrocardia with gastric bubble on the right side and liver on the left. Ultrasonography of the abdomen showed multiple echogenic foci of 3 to 7 mm in size in the gallbladder and common bile duct (CBD) of 6 millimeters. She was diagnosed with symptomatic cholelithiasis and planned for laparoscopic cholecystectomy. Routine preoperative workup was done and was found to be normal
The operating theatre was prepared such that the surgeon and camera assistant were in right side, and, assistant surgeon and the laparoscopic tower in left side of the patient (Figure 2A). The surgeon in this case was right-handed. The patient was kept in supine position with left side slightly elevated. Four ports were created. The first port of 10mm positioned supraumbilically was created, followed by the creation of pneumoperitoneum using carbon dioxide gas. After which, a 10 mm port in epigastric region and two 5 mm ports were positioned in the left mid-clavicular line and left anterior axillary line respectively (Figure 2B).
Diagnostic laparoscopy was performed and the laterality was visualized (Fig 3). The fundus of the gallbladder was then retracted towards the right shoulder and the retraction of the Hartmann’s pouch was done to the left by the assistant. The posterior dissection was then performed for the clearance of the cystic duct and artery. This manoeuvre prevented the crossing of hands of the surgeon. Thus, the Calot’s triangle was identified and dissection of the fibrofatty tissue was done, to achieve the critical view of safety, such that only the cystic artery and duct was seen to be entering the gallbladder. The gallbladder was then slightly separated from its attachment to the liver to expose a part of the cystic plate, following which the cystic artery and the duct were clipped and divided. The gallbladder was then dissected off its liver bed and removed through the umbilical port. On opening of the retrieved gallbladder, two calculi were found inside, with its walls mildly inflamed. This was then then sent for histopathological examination. The 10mm ports were closed using polygalactin 1-0. The histopathological report concluded the diagnosis to be chronic calculous cholecystitis.