Optimizing ergonomics during laparoscopic cholecystectomy in situs inversus abdominis with levocardia: a technical note

Laparoscopic cholecystectomy in patients with situs inversus abdominis with levocardia is technically challenging because of mirror-image anatomy and unfamiliar ergonomics. We describe technical modifications for safe laparoscopic cholecystectomy in a 38-year-old woman with symptomatic cholelithiasis. Preoperative imaging confirmed left-sided positioning of the liver and gallbladder with a normally positioned heart. A modified four-port configuration with mirrored subcostal ports was used, with the surgeon positioned on the patient's right side. Hartmann's pouch was retracted with the dominant right hand, while Calot's triangle was dissected through the epigastric port with the left hand. After adhesiolysis, an anomalous cystic artery located to the right of the cystic duct was identified. The critical view of safety was achieved before division of the cystic structures. The procedure was completed without complications, and the patient was discharged on postoperative day 1. Individualized port placement and surgeon positioning may facilitate safe surgery in patients with situs anomalies.