Laparoscopic cholecystectomy in patients with situs inversus totalis: Two case reports and review of literature

Abstract

BACKGROUND

Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete mirror-image transposition of thoracic and abdominal organs. The presence of gallstone disease in these patients represents a diagnostic and technical challenge, particularly when laparoscopic cholecystectomy is indicated.

CASE SUMMARY

We report two cases of symptomatic gallstone disease in patients with SIT. The first case involved a 27-year-old female diagnosed with cholelithiasis following radiological evaluation, while the second case involved a 45-year-old male presenting with cholelithiasis and choledocholithiasis requiring preoperative endoscopic retrograde cholangiopancreatography. Cases were identified retrospectively from institutional surgical records. Data were collected from clinical charts, imaging studies, operative reports, and follow-up visits. In both patients, laparoscopic cholecystectomy was successfully performed using a mirror-image port placement strategy. No intraoperative or postoperative complications occurred, and both patients were discharged on the first postoperative day.

CONCLUSION

Laparoscopic cholecystectomy in patients with SIT is safe and feasible when meticulous preoperative imaging and careful adaptation of surgical technique are employed. Awareness of mirror-image anatomy and strict adherence to the critical view of safety are essential to minimize the risk of iatrogenic injury.

Key Words: Situs inversus totalis; Laparoscopic cholecystectomy; Cholelithiasis; Choledocholithiasis; Endoscopic retrograde cholangiopancreatography; Mirror-image anatomy; Critical view of safety; Case report

Core Tip: Situs inversus totalis is a rare anatomical condition that presents unique diagnostic and technical challenges during laparoscopic cholecystectomy. This case series emphasizes the importance of thorough preoperative imaging to clearly define biliary anatomy and identify any associated anomalies. It also highlights the need for careful adaptation of surgical technique, including mirror-image port placement and ergonomic adjustments by the surgical team. Strict adherence to the critical view of safety remains essential to minimize the risk of bile duct injury and to ensure safe, effective, and reproducible surgical outcomes.

INTRODUCTION

Situs inversus totalis (SIT) is a rare congenital condition characterized by complete mirror-image transposition of both thoracic and abdominal organs[1]. Its reported incidence ranges from 1 in 5000 live births to 1 in 20000 live births[2]. Although the condition itself is usually asymptomatic, it may pose significant diagnostic and technical challenges when surgical intervention is required, particularly in minimally invasive procedures. In SIT, the heart and stomach are typically located on the right side of the midline, whereas the liver and gallbladder are positioned on the left[3]. In some patients, SIT may be associated with Kartagener syndrome, a subset of primary ciliary dyskinesia characterized by chronic sinusitis, bronchiectasis, and infertility[4]. Gallstone disease in patients with SIT is uncommon, and diagnosis may be delayed due to atypical symptom localization[5]. Advanced imaging modalities are therefore essential to accurately delineate biliary anatomy and facilitate appropriate surgical planning. Laparoscopic cholecystectomy remains the treatment of choice for symptomatic cholelithiasis; however, mirror-image anatomy requires careful adaptation of trocar placement, surgeon positioning, and dissection strategy. Preservation of ergonomic principles and strict adherence to the critical view of safety are fundamental to minimizing bile duct injury[6]. We present two cases of laparoscopic cholecystectomy in patients with SIT and review the relevant literature with emphasis on technical considerations. Case identification and follow-up patients were retrospectively identified from institutional surgical records. Inclusion criteria were a confirmed diagnosis of SIT and symptomatic gallstone disease requiring surgical treatment. Clinical, radiological, operative, and pathological data were reviewed. Postoperative follow-up consisted of outpatient clinical evaluation at 30 days and at 6 months.

CASE PRESENTATION

Chief complaints

Case 1: Intermittent epigastric pain for one year.

Case 2: Intermittent colicky abdominal pain for six months.

History of present illness

Case 1: A 27-year-old female reported intermittent, dull, non-radiating epigastric pain relieved by medication, without associated gastrointestinal or systemic symptoms.

Case 2: A 45-year-old male reported intermittent colicky abdominal pain relieved by medication.

History of past illness

Both patients had no relevant past medical or surgical history.

Personal and family history

No significant personal or family history was reported in either case.

Physical examination

Physical examination was unremarkable in both patients.

Laboratory examinations

Case 1: Laboratory investigations revealed anemia with mild biochemical abnormalities; viral markers were negative (Table 1 and Figure 1).

Figure 1 Chest radiograph. The image demonstrates dextrocardia, with the cardiac apex and aortic knuckle oriented toward the right hemithorax. The liver shadow is visible in the left upper quadrant. R: Right; L: Left; K: Kerley lines; A: Airway; L: Liver.

Table 1 Initial investigations.

Investigations	Value	Normal range
Haemoglobin	9.4 g/dL	13.0-17.0
TLC	9.2 × 103/uL	4.0-10.0
RBS	160 g/dL	80.0-140.0
Liver function tests
SGOT	23 IU/L	0.0-35.0
SGPT	27 IU/L	0.0-41.0
ALP	83 IU/L	40.0-129.0
Albumin	3.2 g/dL	3.5-5.2
Bilirubin	1.4 mg/dL	0.1-1.2
Renal function tests
Serum urea	27 mg/dL	17.0-43.0
Serum creatinine	1.2 mg/dL	0.6-1.1
Serum Na+	135 mmol/L	136.0-145.0
Serum K+	4.2 mmol/L	3.5-5.0
Viral markers
HCV	Non-reactive
HBsAg	Non-reactive
HIV	Non-reactive

TLC: Total leukocyte count; RBS: Random blood sugar; SGOT: Serum glutamic-oxaloacetic transaminase; SGPT: Serum glutamic-pyruvic transaminase; ALP: Alkaline phosphatase; HCV: Hepatitis C Virus; HIV: Human immunodeficiency virus; HBsAg: Hepatitis B surface antigen.

Case 2: Laboratory tests showed elevated bilirubin and alkaline phosphatase levels (Table 1 and Figure 1).

Imaging examinations

Case 1: Chest radiography demonstrated dextrocardia. Abdominal ultrasonography and magnetic resonance cholangiopancreatography confirmed cholelithiasis and SIT (Figure 2).

Figure 2 Magnetic resonance cholangiopancreatography findings. A: Mirror-image biliary anatomy showing the left-sided gallbladder with gallstones, common bile duct, common hepatic duct, and pancreatic duct; B: Axial section demonstrating left-sided liver and gallbladder with the stomach and spleen positioned on the contralateral side. LHD: Left hepatic duct; RHD: Right hepatic duct; CHD: Common hepatic duct; CBD: Common bile duct; PD: Pancreatic duct; GB: Gall bladder; R/L: Right/left.

Case 2: Abdominal ultrasonography revealed gallstones and distal common bile duct calculi. Imaging confirmed SIT (Figure 3).

Figure 3 Intraoperative view of left-sided gallbladder. Laparoscopic visualization of the gallbladder positioned in the left hypochondrium, grasped with an endoscopic instrument.

FINAL DIAGNOSIS

Symptomatic cholelithiasis in SIT (case 1) and cholelithiasis with choledocholithiasis in SIT (case 2) (Figure 4).

Figure 4 Gallbladder specimen examination. A and B: Gross and histopathological findings of the gallbladder specimen. A: Gross specimen showing thickened gallbladder wall with gallstones; B: Histopathological examination (× 100 magnification) revealing epithelial denudation with lymphoid aggregates and mild chronic inflammatory infiltrate; C: Gross examination of the gallbladder specimen. Extracted specimen showing gallstones and intraluminal biliary sludge.

TREATMENT

Both patients underwent elective laparoscopic cholecystectomy using a mirror-image four-port configuration (Figure 5). In both cases, the critical view of safety was achieved prior to division of the cystic duct and artery. Intraoperative findings confirmed left-sided gallbladder anatomy (Figure 6A). Dissection was carried out with careful orientation to Rouvier’s sulcus, and the critical view of safety was achieved before division of the cystic duct and artery (Figure 6B and C). The gallbladder was retrieved through the epigastric port (Figure 6D).

Figure 5 Mirror-image port placement for laparoscopic cholecystectomy. A 10-mm supraumbilical trocar was used for the camera, a 10-mm right flank trocar for the surgeon’s left hand, a 5-mm epigastric trocar for the assistant, and a 5-mm left flank trocar for the surgeon’s right hand.

Figure 6 Intraoperative findings during laparoscopic cholecystectomy. A: Initial laparoscopic assessment demonstrating the liver and gallbladder (white arrow) located in the left hypochondrium, and stomach in the right hypochondrium (white arrow), consistent with situs inversus totalis; B: Dissection of Calot’s triangle. Two tubular structures, corresponding to the cystic duct and cystic artery, are visualized entering the gallbladder (yellow arrow: Cystic artery and duct); C: Control of cystic structures (yellow arrow: Cystic artery and duct). Application of surgical clips to the cystic duct prior to division; D: Critical view of safety. The cystic duct and cystic artery (white arrows) are clearly identified entering the gallbladder, with the lower third of the gallbladder dissected free from the liver bed and complete exposure of Calot’s triangle, following the clinical view of the safety rule.

OUTCOME AND FOLLOW-UP

Both patients had an uneventful postoperative course and were discharged on postoperative day one. Clinical follow-up at 30 days and 6 months revealed no complications or recurrent biliary symptoms.

DISCUSSION

SIT results from abnormal left-right axis determination during early embryogenesis. Although the exact mechanisms remain incompletely understood, disruptions in molecular signaling pathways during gastrulation have been implicated. Unlike intestinal malrotation, SIT involves a complete mirror-image arrangement of thoracic and abdominal organs without rotational anomalies of foregut-derived structures. The prevalence of gallstone disease in patients with SIT appears comparable to that of the general population; however, clinical presentation is often atypical, with pain localized to the left upper quadrant or epigastrium. This may lead to diagnostic delay unless a high index of suspicion is maintained. Consequently, preoperative imaging plays a pivotal role in confirming biliary anatomy and identifying associated anomalies[7].

Since the first report of laparoscopic cholecystectomy in SIT in 1991[8], more than 40 cases have been described in the literature, with an increasing number reported in recent years. Cumulative evidence consistently demonstrates that laparoscopic cholecystectomy is safe and feasible in this setting, with low complication rates and favorable postoperative outcomes. The primary technical challenge arises from mirror-image anatomy, which affects surgeon orientation, port placement, and hand dominance. Most authors advocate a mirrored four-port configuration that preserves triangulation and ergonomic principles. Surgeon positioning varies among reports, and no single approach has proven superior; therefore, operative strategy should be tailored to surgeon experience and institutional practice[9,10]. Achievement of the critical view of safety remains the cornerstone of safe cholecystectomy in SIT. Meticulous dissection and unequivocal identification of the cystic duct and artery are mandatory to prevent bile duct injury. Selective use of intraoperative cholangiography may be considered in cases with unclear anatomy or associated choledocholithiasis. Although alternative approaches such as single-incision laparoscopic cholecystectomy[11,12] have been reported, evidence remains limited to isolated cases, and no clear advantage over conventional multi-port techniques has been demonstrated (Table 2)[3,10,13-36]. Furthermore, laparoscopic cholecystectomy in SIT represents a unique challenge for surgical training, reinforcing the importance of adaptability, spatial awareness, and strict adherence to safety principles[14].

Table 2 Cases of situs inversus totalis presenting with cholelithiasis and their treatment, as reported in the literature (2018-2025).

Ref.	Age (in years) and sex	Symptoms	Diagnoses	Treatment
AlKhlaiwy et al[3], 2019	40, male	Epigastric and left upper quadrant pain for 1 month, associated with intermittent nausea and vomiting	Cholelithiasis	Laparoscopic cholecystectomy
Ponce et al[13], 2020	61, female	Colic abdominal pain, with predominance of it in the left upper quadrant, associated with nausea, of weekly frequency	Cholelithiasis	Laparoscopic cholecystectomy
Du et al[14], 2020	56, female	Nausea, severe chest pain, and epigastric pain	Cholelithiasis	Laparoscopic cholecystectomy
Lakhey et al[10], 2025	30, female	Colicky abdominal pain located over the epigastric and left hypochondrium regions	Cholelithiasis	Laparoscopic cholecystectomy
Jhobta et al[15], 2018	23.female	Intermittent left upper abdomen discomfort and dyspepsia	Cholelithiasis	Laparoscopic cholecystectomy
Jang et al[16], 2019	37, male	Persistent indigestion	Chronic cholecystitis with gallstones	Laparoscopic cholecystectomy
Sheik-Ali et al[17], 2019	57, female	Epigastric pain	Acute cholecystitis	Laparoscopic cholecystectomy
Mohammed and Arif[18], 2019	28, male	Epigastric pain and left hypochondrial pain	Cholelithiasis	Laparoscopic cholecystectomy
Hernández-Marín and Guevara-Valerio[19], 2020	66, male	Epigastric pain	Cholelithiasis	Laparoscopic cholecystectomy
Herrera Ortiz et al[20], 2021	46, female	Non-bilious vomiting and left-sided abdominal pain	Symptomatic cholelithiasis	Laparoscopic cholecystectomy
Garnica-Rosales et al[21], 2021	26, female	Sudden, intense abdominal pain in the left hypochondrium	Cholelithiasis	Laparoscopic cholecystectomy
Meng et al[22], 2022	32, male	Left upper abdominal pain	Chronic cholecystitis	Laparoscopic cholecystectomy
He et al[23], 2022	53, female	Intermittent left upper abdominal pain	Cholelithiasis	Laparoscopic cholecystectomy
Montalvo-Javé et al[24], 2022	44, female	Colicky epigastric pain that radiated to the right scapula	Cholelithiasis	Laparoscopic cholecystectomy
Suleimanov et al[25], 2022	38, female	Left upper abdominal and epigastric pain and nausea	Cholelithiasis	Laparoscopic cholecystectomy
Abu-Oddos et al[26], 2023	24, male	Epigastric pain	Cholelithiasis	Laparoscopic cholecystectomy
M et al, 2023[27]	Middle-aged male	Pain in the left hypochondrium	Cholelithiasis	Laparoscopic cholecystectomy
Raut et al[28], 2023	38, male	Backache and vomiting	Cholelithiasis	Laparoscopic cholecystectomy
Nguyen et al[29], 2024	33, female	Episodic left upper quadrant pain and diffuse epigastric pain	Cholelithiasis	Laparoscopic cholecystectomy
Nassr et al[30], 2024	34, female	Left upper quadrant pain	Cholelithiasis	Laparoscopic cholecystectomy
Althunayan et al[31], 2024	40, female	Pain was located in LUQ, radiating to the back, associated with vomiting	Cholelithiasis	Laparoscopic cholecystectomy
Cunningham et al[32], 2024	54, male	Epigastric pain, dysphagia, and weight loss	Cholelithiasis	Laparoscopic cholecystectomy
Abdullah et al[33], 2025	52, male	Intermittent left upper quadrant abdominal pain	Cholelithiasis	Laparoscopic cholecystectomy
Vázquez-Guerra et al[34], 2025	49, female	Repetitive postprandial colic pain in the epigastrium	Acute calculus cholecystitis	Laparoscopic cholecystectomy
Li et al[35], 2025	67, female	Abdominal pain	Cholecystolithiasis	Laparoscopic cholecystectomy
Wu et al[36], 2025	73, female	Epigastric pain	FGBD and potential gallbladder ectopia	Laparoscopic cholecystectomy

LUQ: Left upper quadrant; FGBD: Functional gallbladder disease.

CONCLUSION

Laparoscopic cholecystectomy in patients with SIT is safe and feasible when supported by thorough preoperative imaging and careful adaptation of surgical technique. Awareness of mirror-image anatomy, appropriate port placement, and strict adherence to the critical view of safety are essential to achieving favorable outcomes and minimizing iatrogenic injury.