Incidental Chilaiditi Sign Identified During Evaluation for Symptomatic Cholelithiasis: Implications for Surgical Planning

The Chilaiditi sign is a rare radiographic finding characterized by the interposition of the colon between the liver and the right hemidiaphragm. Although typically asymptomatic, it may complicate upper abdominal procedures or mimic pneumoperitoneum. We present a 73-year-old male with symptomatic cholelithiasis whose preoperative computed tomography (CT) imaging incidentally revealed the Chilaiditi sign. Given this finding, the standard umbilical approach for peritoneal access was avoided, and pneumoperitoneum was instead established via left upper quadrant (LUQ) Veress needle insertion to reduce the risk of injury to the interposed colon. Port placement was similarly adjusted away from the right upper quadrant. The procedure was completed without complications, and the patient was discharged on postoperative day four. This case highlights the importance of recognizing the Chilaiditi sign on preoperative imaging, as identification of this anatomic variant can directly influence peritoneal entry technique, trocar positioning, and overall operative safety during laparoscopic procedures.