Acute Cholecystitis in Two Patients Carrying a Situs Inversus : A Diagnostic and Therapeutic Challenge

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.


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 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 epiploon of the gallbladder. After puncture draining of the gallbladder (hydrocholecystis), a dissection of the canal and the cystic artery in hook with the left hand was made ( Figure 4). After clipping and section of the

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][6][7][8][9][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. canal and the Cystic artery ( Figures 5 and 6), retrograde cholecystectomy was performed. Finally, the gallbladder was extracted in a bag.