EAES Academy

Laparoscopic cholecystectomy has been the standard of surgical care for symptomatic gallstones for more than two decades, but the learning curve for this highly standardized procedure is still difficult to significantly reduce the risk of injury to noble structures in the Calot triangle.
Surgery in patients with situs inversus totalis is a technical challenge and although many authors recommend that it be performed by an experienced surgeon, the operation can be a success for any operator if the approach is carefully studied preoperatively. Preoperative imaging (tomography or magnetic resonance imaging) is considered useful to assess any vascular or bile duct abnormalities that may increase the risk of intraoperative injury.
The most important element, however, remains the location of the work trocars, the positioning of the surgeon and the assistant, in order to attain critical view of safety and the safe conclusion of the intervention. Several surgical options have been proposed that improve operative ergonomics: surgeon and trocars positioned "in the mirror" compared to the classic position, surgeon and patient in French position, with trocars positioned in a classic or modified location, optical trocar in subumbilical position, or single-port surgery where possible. The challenge is to make maximum use of the surgeon's dexterity for a routine and highly standardized but mirrored operation. Following the analysis of several studies in the literature and extensive preoperative planning, we present the technique used in our clinic for a 38-year-old patient with situs inversus totalis and calculous cholecystitis.