Urgent laparoscopic cholecystectomy in a patient with situs inversus totalis: a case report and literature review

Introduction: Situs inversus totalis (SIT) is a rare congenital condition characterized by the complete mirror-image transposition of thoracic and abdominal organs. Acute cholecystitis in patients with SIT often presents with atypical left-sided abdominal or chest pain, which may mimic cardiopulmonary emergencies and lead to diagnostic delays, particularly in acute care settings. Case presentation: A 29-year-old woman presented with left upper quadrant abdominal pain radiating to the left chest and shoulder, associated with mild dyspnea, nausea, and a low-grade fever. Initial investigations excluded acute coronary syndrome. Electrocardiography demonstrated features suggestive of dextrocardia, including right-axis deviation and lead I inversion. Chest radiography revealed dextrocardia, and subsequent abdominal ultrasonography and computed tomography confirmed SIT with a left-sided gallbladder showing features of acute calculous cholecystitis. Laboratory tests demonstrated leukocytosis and elevated C-reactive protein. The patient underwent urgent laparoscopic cholecystectomy using a mirror-image port configuration. The procedure was completed safely without complications. Histopathological examination confirmed acute calculous cholecystitis. Postoperative recovery was uneventful, and the patient remained asymptomatic at a 4-month follow-up. Discussion: Urgent laparoscopic cholecystectomy in SIT is technically demanding due to reversed anatomy and altered ergonomics, particularly for right-handed surgeons. In this case, specific intraoperative adaptations included mirror-image port placement, surgeon positioning on the patient’s right side, and ergonomic modifications to facilitate dissection of Calot’s triangle. However, with adequate preoperative imaging, awareness of anatomical variations, and appropriate modification of port placement and surgical technique, the procedure can be performed safely with outcomes comparable to those in patients with normal anatomy. Conclusion: Acute cholecystitis in patients with SIT may present with misleading left-sided symptoms. Early recognition through imaging and adaptation to mirror-image anatomy allow for safe and effective urgent laparoscopic management. Awareness of this rare condition is essential to avoid diagnostic delays and operative complications.