Posterior approach to Calot’s triangle in situs inversus totalis: A case report and review of literature

doi:10.4240/wjgs.119179

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World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastrointest Surg. Jun 27, 2026; 18(6): 119179
Published online Jun 27, 2026. doi: 10.4240/wjgs.119179

Posterior approach to Calot’s triangle in situs inversus totalis: A case report and review of literature

Mao-Lin Chen, Xiao Ma, Le Xiao, Tian-Tian Chen, Zhu-Lin Luo, Xiao-Dong Xie

Mao-Lin Chen, Zhu-Lin Luo, Department of Hepatobiliary Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China

Mao-Lin Chen, Xiao Ma, Le Xiao, Tian-Tian Chen, Zhu-Lin Luo, Xiao-Dong Xie, Department of General Surgery, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China

Co-corresponding authors: Zhu-Lin Luo and Xiao-Dong Xie.

Author contributions: Chen ML designed the study and drafted the manuscript; Chen ML and Ma X contributed to the data collection, literature review, and data analysis; Ma X and Xie XD performed the surgical intervention; Ma X, Xiao L, Luo ZL, and Xie XD contributed to manuscript revision; Xiao L contributed to data interpretation; Chen TT collected case information, organized the imaging materials, and prepared the tables and figures; Luo ZL and Xie XD contributed equally as co-corresponding authors, providing overall supervision and critical revision. All authors approved the final manuscript.

AI contribution statement: During the preparation of this manuscript, the authors used ChatGPT only to translate portions of the text, correct grammar, and polish the language. The AI tool was not used to generate any academic content, nor was it involved in the study design, data analysis, interpretation of results, formulation of conclusions, or figure generation. After using the AI tool, the authors carefully reviewed, revised, and verified the relevant content. The authors take full responsibility for the academic content and views expressed in the manuscript.

Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

Corresponding author: Xiao-Dong Xie, PhD, Professor, Department of General Surgery, The General Hospital of Western Theater Command, No. 270 Rongdu Road, Jinniu District, Chengdu 610083, Sichuan Province, China. xiexiaodong10@yeah.net

Received: January 22, 2026
Revised: February 17, 2026
Accepted: March 23, 2026
Published online: June 27, 2026
Processing time: 149 Days and 13.2 Hours

Abstract

BACKGROUND

Situs inversus totalis (SIT) is a rare congenital anomaly in which the thoracic and abdominal viscera are completely mirrored, complicating spatial orientation and surgical techniques during laparoscopic cholecystectomy (LC). With the conventional anterior approach, this mirrored anatomy often causes instrument crossing, restricted manipulation, and surgeon disorientation. The posterior approach may offer a more ergonomic pathway aligned with the mirror-image anatomy, but its clinical utility and technical rationale in SIT remain incompletely defined.

CASE SUMMARY

A 33-year-old man with SIT presented with a 6-month history of intermittent upper left quadrant abdominal pain, which had worsened over the preceding month. He was diagnosed with chronic cholecystitis with focal necrosis (gangrenous change). A three-port LC was performed in a mirror-image modified American position using a posterior approach to Calot’s triangle. The procedure was completed uneventfully within 64 minutes, with no biliary injury or perioperative complications. A closed-suction drain was placed intraoperatively and removed on postoperative day 3. The patient was discharged on postoperative day 4 and remained asymptomatic at the 3-month follow-up, with no evidence of bile leakage or surgical-site infection.

CONCLUSION

For SIT patients undergoing LC, accessing Calot’s triangle via the posterior approach is a feasible surgical strategy.

Keywords: Situs inversus totalis; Laparoscopic cholecystectomy; Mirror-image anatomy; Posterior approach to Calot’s triangle; Case report

Core Tip: Mirror-image anatomy in situs inversus totalis can increase ergonomic and cognitive demands during laparoscopic cholecystectomy, particularly when Calot’s triangle dissection is challenging. We describe a posterior approach to Calot’s triangle as a stepwise access strategy in which a posterior window is developed and dissection proceeds in a posterior-to-anterior direction to facilitate sequential anatomic confirmation. This pathway may help limit instrument crossing and reduce the need for repeated reorientation in situs inversus totalis cases while maintaining adherence to the critical view of safety principles.