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Page 2 of 4 Tirelli et al. Mini-invasive Surg 2021;5:15 https://dx.doi.org/10.20517/2574-1225.2021.04

[2]
abdominal organs) . Because of this particular anatomy, it could be challenging for the surgeon to perform
[3]
any abdominal procedure, including laparoscopic cholecystectomy . The “mirror image” is critically
confusing, especially during the dissection of the Calot’s triangle. In these situations, indocyanine green
fluorescence cholangiography can be essential. It can allow highlighting and safely preserving all the biliary
structures .
[4,5]

CASE REPORT
A 29-year-old female, BMI 24.2 kg/m , was admitted to the authors’ institution with diagnosed symptomatic
2
presence of stones in the gallbladder with several episodes of epigastric pain, nausea, and vomiting. Medical
history showed Kartagener’s syndrome (DNAH5 gene mutation) with documented situs viscerum inversus
totalis, bronchiectasis, and recurrent respiratory infections (the last episode occurring 18 months before the
surgery). During a hospitalization in another institution due to bronchopneumonia, the patient underwent
CT scan that showed gallbladder stones. Before the surgery, the patient underwent abdomen ultrasound and
MRI as well.

The patient underwent laparoscopic cholecystectomy with a four-trocar technique. The operating surgeon
was on the right side of the patient and the assistant was between the patient’s legs. First, a 12-mm trocar
was placed in the sub-umbilical portion. After inducing the pneumoperitoneum, three 5-mm trocars were
placed in the epigastrium, mesogastrium, and left flank, respectively. A diagnostic laparoscopy confirmed
the SVI. Twenty-five milligrams of indocyanine green were diluted into 10 mL of sterile normal saline, and
a bolus of 0.2 mg/kg was injected intravenously by the anesthesiologist 1 h before the surgery.

During the procedure, the operating surgeon started the dissection of the Calot’s triangle by means of a
diathermy hook. Switching the vision to the near-infrared camera, which elicited the indocyanine green
molecules, the surgeon could easily identify the common bile duct and the cystic duct. Switching back to the
normal vision, the operator completed the dissection. After being isolated, the cystic duct and the cystic
artery were clipped, cut, and a retrograde cholecystectomy was performed with no difficulties. The
operation took 74 min without intraoperative complications. The patient was discharged on Postoperative
Day 2 uneventfully. The final pathology confirmed calculous cholecystitis.

DISCUSSION
The described procedure is still challenging due to the “mirror effect” and the uncommon position of the
surgical instruments. For right-handed surgeons, the use of the non-dominant hand to perform the
dissection could be challenging. Because of this, surgeons should reflect, first, on the trocars position. Some
authors described a simple mirror trocar’s position to perform this surgery , but we suggest reconsidering
[6]
this simplification for right-handed surgeons and rethinking the use of the instruments. As described in a
recent review , there is no standard technique to approach this uncommon orientation. Differently from
[7]
what is described in other papers [3,7,8] , our equipment was composed by a surgeon and an assistant, and they
decided the best port placement that allows the surgeon to perform the dissection with the right hand,
having full control of the instrument and completely relying on the assistant for the necessary tractions on
the gallbladder to reach the critical view of safety. By this, we tried to avoid the risk of vascular or biliary
injury possibly due to the uncommon anatomy.

Thus, the patient’s position was halfway between a mirrored “French” and “American” position because the
patient was placed in a lithotomy position but with the surgeon on the patient’s right and the assistant
between the patient’s legs. The surgeon’s 5-mm operating trocar was placed midline, between the 5-mm one
in the epigastrium and the 12-mm one in the navel. The surgeon was right-handed and used the trocar in