Discussion
SIT is a rare condition characterized by the complete transposition of both the thoracic and the abdominal viscera along the left-right axis, thus forming a mirror image of the normal anatomical picture.1 SIT alone is asymptomatic, except for the accompaniment of cardiac anomalies associated with dextrocardia, such as atrial situs solitus, discordant atrioventricular (AV) connection, and to a lesser extent congenitally corrected transposition of great arteries (TGA).6,9 Situs inversus is closely associated with a condition known as PCD. Fifty percent of the patients with PCD are associated with situs inversus, and together is known as Kartagener’s Syndrome. 10,11 However, there isn’t enough evidence that establish the association between SIT and gallbladder disease. 6,12
While the diagnosis of symptomatic cholelithiasis in patients with SIT is challenging, since our patient was diagnosed with it on routine health checkup prior to the development of illness, no particular challenge was faced in this case. The first successful laparoscopic cholecystectomy in a patient with situs inversus was performed in 1991 by Campos and Sipes.13 In a similar report, Arya et al. performed the procedure by placing the ports and the instruments in a mirror-image fashion to the conventional laparoscopic cholecystectomy. The primary surgeon performed the dissection, while the first assistant retracted the Hartmann’s pouch throughout the surgery, thus preventing the crossing of the hands of the right-handed surgeon.14 However, Alam and Santra reported conduction of the procedure with the first assistant holding the camera through the infraumbilical port and the second assistant retracting the Hartmann’s pouch.8
Other procedures have also been reported with several modifications. One of them being adopting the Llyod-Davis Position, with the primary surgeon standing in between the abducted legs of the patient.14,15 Cases of Single incision Laparoscopic Surgery (SILS) have also been reported, with the aim of reducing invasiveness, improving cosmesis, and avoidance of the crossing of the instruments.16,17