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ISSN: 2165-7920
Journal of Clinical Case Reports
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Acute Cholecystitis in Two Patients Carrying a Situs Inversus: A Diagnostic and Therapeutic Challenge

Anis Haddad*, Amine Sebai, Souhaib Atri, Amine Daghfous and Zoubeir Ben Safta

Department of Surgery, La Rabta Hospital, Tunis, Tunisia

*Corresponding Author:
Anis Haddad
Department of Surgery, La Rabta
Hospital, Tunis, Tunisia
Tel: +216 71 562 083
E-mail: [email protected]

Received Date: March 30, 2017 Accepted Date: July 22, 2017 Published Date: July 27, 2017

Citation: Haddad A, Sebai A, Atri S, Daghfous A, Safta ZB (2017) Acute Cholecystitis in Two Patients Carrying a Situs Inversus: A Diagnostic and Therapeutic Challenge. J Clin Case Rep 7: 1000. doi: 10.4172/2165-7920.10001000

Copyright: © 2017 Haddad A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

The situs inversus is a rare anatomical condition which is characterized by the transposition of organs towards the opposite side. The left position of the gall-bladder makes the diagnosis of acute cholecystitis difficult because of an unusual symptomatology. It is also associated with a difficulty of laparoscopic dissection of the stone-block triangle especially for the right-handed surgeons. We report the cases of 2 patients whose different explorations confirmed the diagnosis of acute cholecystitis and total situs inversus and benefited from a laparoscopic cholecystectomy. Laparoscopic cholecystectomy, in these two cases, is an original intervention because of the mirrored vision of the intraperitoneal organs and can even be difficult leading to iatrogenic complications. However, the laparoscopic approach remains the gold standard even in the presence of this mirrored anatomy.

Keywords

Gallbladder; Cholecystitis; Cholecystectomy

Introduction

The situs inversus is a rare anatomical condition which is characterized by the transposition of organs towards the opposite side. Its incidence is estimated from 1/10000 to 1/20000. The left position of the gall-bladder makes the diagnosis of acute cholecystitis difficult because of an unusual symptomatology. It is also associated with a difficulty of laparoscopic dissection of the stone-block triangle especially for the right-handed surgeons. We report the cases of 2 patients carrying a totalsitus inversus who benefited from a laparoscopic cholecystectomy for acute cholecystitis.

Case Report

Case 1

Sir. B, 58-year-old, male was hospitalized for a painful and feverish syndrome of the left hypochondrium. The physical examination found an anicteric patient with fever at 38.5°C and a defense of the left hypochondrium.

The chest X-ray of the thorax (Figure 1) showed a dextrocardia suggesting the diagnosis of situs inversus. Pre, per and post-operative findings are summarized in (Table 1). Abdominal ultrasound confirmed the diagnosis of acute cholecystitis and total situs inversus. The patient was operated on under laparoscopy with a standard installation: surgeon between the patient’s legs, the first aid at the right of the patient. The trocars were then introduced: The first trocar of 10 mm at the level of the umbilicus (for the camera), the second trocar of 10 mm at the level of the right side, then two other trocars of 5 mm respectively into the left iliac pit and into the epigastrium. Thus, the disposal of the trocars was the symmetric of the usual provision (Figures 2 and 3). The exploration intraoperative confirmed the diagnosis of acute cholecystitis and the situs inversus (Figure 4). First, we proceeded to the liberation of the canal and the Cystic artery (Figures 5 and 6), retrograde cholecystectomy was performed. Finally, the gallbladder was extracted in a bag.

clinical-case-reports-dextrocardia

Figure 1: Chest X-ray showing dextrocardia.

clinical-case-reports-Trocars-7

Figure 2: Trocars.

clinical-case-reports-Trocars

Figure 3: Trocars.

clinical-case-reports-per-surgery

Figure 4: In per-surgery: Gall-bladder located at the level of the left hypochondrium, to the left of the round ligament.

clinical-case-reports-Gallbladder

Figure 5: Gallbladder after its liberation of its bed.

clinical-case-reports-Clipped-cystic

Figure 6: Clipped cystic duct.

Variables  Case 1 Case 2 Cholecystectomy for acute cholecystectomy with a right sided gallbladder
Fever 38.5°C 38.1°C 38.2°C
Abdominal pain Left hypochondrium Left hypochondrium Right hypochondrium
Wall defense Yes Yes Yes
WBC (/mm3) 16740 12000 13500
CRP (mg/l) 140 70 90
Operative time (min) 60 75 45
Drainage No No No
Postoperative temperture 37.2°C 37,4°C 37,5°C
Time of first bowel movement 24 hours after surgery 24 hours after surgery 24 hours after surgery
Mobilization of the patient 12 hours after surgery 12 hours after surgery 12 hours after surgery
Antibiotics C3G+Metronidazole *15 days C3G+Metronidazole *15 days C3G+Metronidazole *15 days
LMWH Enoxaparine 4000 UI, one injection/day, for 5 days Enoxaparine 4000 UI, one injection/day, for 5 days Enoxaparine 4000 UI, one injection/day, for 5 days
Pain killer Paracetamol Paracetamol Paracetamol
Wound healing One week One week One week
Hospital staying 3 days after surgery 3 days after surgery 3 days after surgery

Table 1: Pre, per and post operative findings of the patients.

Case 2

Mr. SN, 54-year-old, male was hospitalized for fever and pain of the left hypochondrium. This patient was known carrier of a situs inversus complete. The radiological and biological explorations confirmed the diagnosis of acute cholecystitis on total situs inversus. The patient was operated then under laparoscopy with the same installation and provision of the trocars as in the first observation. Intraoperative exploration confirmed the diagnosis of cholecystitis (Figure 7). Pre, per and post-operative findings are summarized in Table 1.

clinical-case-reports-hypochondrium

Figure 7: In per-surgery: Gallbladder located at the level of the left hypochondrium, to the left of the round ligament.

Discussion

The situs inversus is a rare anatomical condition which is characterized by the transposition of organs towards the opposite side. Its incidence is estimated from 1/10000 to 1/20000 [1]. Two types are described: the partial situs inversus in which either the intrathoracic organs or those intra-abdominal are transposed and the complete situs inversus in which all the organs are transposed. It can join certain anomalies such as bronchiectasis, sinusitis and a deficit of the tracheobronchial lashes entering then within the framework of a syndrome of Kartagener. In such patients, acute cholecystitis usually manifests as a painful and feverish syndroma of the left hypochondrium. However, in 30% of cases, there are isolated epigastric distress and in 10% of cases a painful and feverish syndroma of the right hypochondrium [2]. This is explained by the fact that the central system may not be converted [3]. Diagnosis is difficult in this atypical presentation, especially if the patient is not known carrier of a situs inversus. However, it should be mentioned if the chest X-ray found a dextrocardia or if a right axis is highlighted by the ECG of the patient. Other explorations, and in particular the abdominal ultrasound, will allow to make the diagnosis of acute cholecystitis and situs inversus.

Only 67 cases of laparoscopic cholecystectomy with situs inversus were listed in the literature until now [4]. The laparoscopic access of the gall bladder, in case of a situs inversus, is difficult especially for the righthanded surgeons, and this may lead to lesions of the principal bile duct while dissecting the stone-block triangle especially that the anatomical alternatives of the bile ducts are more frequent in the event of a situs inversus. Several adaptations of the surgical technique were described [2,5-10]. For our two patients, the symmetric of the usual disposition of the trocarts was carried out. The cholecystectomy was more laborious than for a subject with “a right gallbladder” but not especially difficult.

Conclusion

Situs inversus is a rare anatomical situation that makes the diagnosis of acute cholecystitis difficult due to a left symptomatology. Laparoscopic cholecystectomy, in this case, is an original intervention because of the mirrored vision of the intraperitoneal organs and can even be difficult leading toiatrogenic complications. However, the laparoscopic approach remains the gold standard even in the presence of this mirrored anatomy.

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