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.