Single-port laparoscopic cholecystectomy in situs inversus totalis using the E.K. glove port
A 65-year-old man presented with 1-year history of intermittent epigastric and left upper quadrant discomfort and concomitant digestive problems. Abdominal ultrasonography revealed gallstones, and that the liver and gallbladder were located in the left upper quadrant, whereas the spleen and stomach were located on the right side. A pre-operative chest X-ray showed dextrocardia []. Laboratory data were normal. After obtaining the patient's informed consent, surgery was performed.\nThe patient underwent general anaesthesia and was positioned supine on the operating table. The surgeon stood on the right side of the patient with the assistant on the left side of the surgeon. The scrub nurse and the monitor were on the left side of the patient []. A standard 10 mm, 30o angled rigid laparoscope with a vertical light cable was used. One articulating laparoscopic grasper (roticulator endo grasp, Covidien), for the left hand and standard rigid 5 mm laparoscopic instruments for the right hand were used in this operation.\nA 2.5 cm completely intra-umbilical, vertical skin incision was performed. The incision was deepened to enter the peritoneal cavity. The inner flexible ring, fitted with the glove was then introduced into the abdomen. The open end of the glove was then wrapped around the outer rigid ring []. Co2 pneumoperitoneum was induced and the patient was then put in reverse Trendelenburg position and tilted slightly right laterally for the remainder of the procedure.\nSIT was confirmed with the telescope inserted via the E.K. Glove port[] in the umbilicus. The liver and the gallbladder were confirmed to be on the left-side [], whereas the spleen, the stomach and the heart beat were seen on the right.\nA tuft or bun was made with the tail end of the No.1-0 nylon suture. The needle was passed through the fundus of the gall bladder, care being taken to pass the needle through the serosa without puncturing the lumen. It was next passed through the peritoneum below the diaphragm. The needle was then brought out through the left subcostal region. When the thread was pulled from outside and fixed with a haemostat, a good retraction of the gallbladder imitating retraction accordance to conventional technique for safe cholecystectomy was achieved []. The entire gallbladder, except for the fundus was covered with dense adhesions, which were lysed using the Maryland grasper and monopolar diathermy current. The cystic artery and duct were identified, dissected [] and clipped with 10 mm clip applicators separately and divided with a pair of scissors.\nNext, the gallbladder was grasped with the left hand grasper and retracted in various directions so that it could be dissected from the liver bed by hook electrocautery in an infundibulum-to-fundal direction.\nThe specimen was retrieved through the E.K. Glove port.[] The fascial defect was closed using 1-0 Prolene (Ethicon) and the skin was approximated using 3-0 polyglycolic Rapide suture (Ethicon) []. The procedure took 70 min and the operative blood loss was minimal. Our patient had an uneventful post-operative course and was discharged on the second post-operative day. Pathologic examination confirmed cholelithiasis with chronic cholecystitis. The patient was followed up and has remained well.