Single-Site “Marionette” Approach to Situs Inversus Cholecystectomy

Lee Stratton, MD, Justin Gerard, MD, Allison G. McNickle, MD, Steven R. Bonomo, MD

Department of Surgery, Mount Sinai Hospital Medical Center, Chicago, Illinois (Dr Stratton), Department of Surgery, Rush University Medical Center, Chicago, Illinois (Dr Gerard), Department of Surgery, University of Nevada–Las Vegas School of Medicine, Las Vegas, Nevada (Dr McNickle), Department of Surgery, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois (Dr Bonomo).


Introduction: Situs inversus totalis is a rare congenital condition that involves sagittal mirroring of all thoracic and abdominal organs. The mirrored anatomy poses a challenge to the surgeon performing intra-abdominal surgery. Several laparoscopic techniques have been described for cholecystectomy in these patients.

Case Description: A 50-year-old woman with situs inversus totalis presented with left upper quadrant pain, cholelithiasis, and clinical findings consistent with acute cholecystitis. She underwent laparoscopic cholecystectomy with a single-site, “marionette” technique. This entailed a single periumbilical incision with 2 trocars (for camera and dissecting instrument) with suture suspension of the infundibulum, body, and fundus of the gallbladder, to facilitate manipulation and visualization.

Discussion: Several case reports have described safe completion of laparoscopic cholecystectomy in the setting of situs inversus totalis by using either mirroring of the traditional 4-port arrangement or a single port, multichannel apparatus. This article describes a single-site, marionette technique that circumvents many of the ergonomic and technical short- comings of approaches described elsewhere.

Key Words: Gallbladder, Situs Inversus, Single-Site Laparoscopic Cholecystectomy.

Download (PDF, 246KB)