A Case of Situs Inversus Totalis with Gallbladder Stones Treated by Laparoscopic Surgery

Situs inversus totalis, known as mirror man, is an extremely rare anatomical variant of human viscera, referring to complete thoracic and abdominal visceral inversion, in which the anatomical parts are opposite to those of normal humans^1,2. There are two main views on the mechanism of its occurrence: visceral rotation disorders during embryonic development³ and abnormal genes carried on the chromosomes of both parents⁴. When combined with other conditions, such as gallbladder stones, surgical interventions become considerably more challenging⁵. The surgical management of gallbladder stones in patients with situs inversus totalis requires specific adjustments, including detailed preoperative imaging to assess anatomical variations and meticulous intraoperative techniques to navigate the mirrored anatomy^5,6. The combination of gallbladder stones in patients with situs inversus totalis is much rarer in clinical practice, and the surgical difficulty of performing laparoscopic cholecystectomy is greater, with a higher risk of intraoperative injury⁷. Conventional laparoscopic cholecystectomy protocols are designed for normal anatomy, leading to potential disorientation, instrument manoeuvrability issues, and increased complication risks in situs inversus totalis cases. Thus, there is a critical need to report standardized, adaptable protocols that address these anatomical challenges while maintaining minimally invasive benefits. In March 2023, our department admitted a case of situs inversus totalis combined with gallbladder stones. We hereby report an optimized three-port laparoscopic cholecystectomy protocol and its outcomes, providing practical guidance for clinical teams.

Case Presentation

A 58-year-old woman presented with recurrent left-sided low back pain lasting more than 2 months, which had worsened during the preceding 2 days. She denied nausea, vomiting, diarrhoea, fever, or jaundice. Her medical, surgical, and family histories were unremarkable, and she had no known chronic diseases. Initially, she sought treatment at a local gastroenterology clinic, where she was managed for suspected gastric disease without symptom relief. Two days before admission, her pain intensified, prompting evaluation at the cardiology clinic of our hospital. Abdominal ultrasonography revealed gallbladder stones with complete visceral inversion, and she was referred to the surgical department for further assessment and treatment. On admission, physical examination demonstrated localized tenderness in the left upper abdomen without rebound tenderness or guarding. Vital signs were stable. Laboratory tests, including a complete blood count and liver function tests, were within normal limits.

Diagnosis, Assessment, and Plan

Preoperative imaging was performed to confirm the diagnosis and evaluate anatomical variations. Magnetic resonance cholangiopancreatography (MRCP) demonstrated gallbladder stones without evidence of biliary tract malformation or stenosis (Figure 1). The final diagnosis was cholelithiasis associated with situs inversus totalis. Differential diagnoses included peptic ulcer disease, renal colic, and left-sided cardiac pain, reflecting the atypical localization of visceral pain. Given the absence of biliary anatomical abnormalities and the patient's stable condition, laparoscopic cholecystectomy was selected as the definitive treatment to minimize surgical trauma and postoperative morbidity. Potential risks, including biliary injury, bleeding and technical challenges associated with the mirrored anatomy, were discussed in detail. The procedure was performed by a surgeon specialising in liver and biliary tract surgery with 15 years of experience in minimally invasive biliary procedures. Written informed consent for surgery and publication of the case was obtained from the patient.

The procedure was approved and conducted as per the ethical guidelines of the First Affiliated Hospital of Baotou Medical College. The patient provided written informed consent for publication of this case report, including all details and images. The consent form was explained to the patient to ensure understanding of the purpose of publication and the information to be shared. All personal identifying information was anonymized in accordance with ethical guidelines and hospital policies to protect patient privacy.

1. Patient positioning and anesthesia

1. The patient was placed under general anesthesia and positioned in the reverse Trendelenburg position, with the left side elevated approximately 30 degrees. This setup was opposite to the conventional position used in standard laparoscopic cholecystectomy, in which the right side is typically elevated, with the display screen positioned on the patient's left side and the surgeon and first assistant standing on the patient's right side, and pneumoperitoneum was established at 12 mmHg during trocar insertion and then reduced to 10 mmHg for maintenance.

2. Trocar placement

1. General anesthesia was induced with propofol (2 mg/kg intravenously), fentanyl (2 µg/kg), and rocuronium (0.6 mg/kg) for neuromuscular blockade and was maintained with sevoflurane (1.5%-2.0% end-tidal concentration) and remifentanil (0.1-0.2 µg/kg/min).
2. The patient was positioned in the reverse Trendelenburg position, with the left side elevated approximately 30 degrees using a surgical body. This setup was opposite to the conventional position used in standard laparoscopic cholecystectomy. The display screen was positioned on the patient's left side, and the surgeon and first assistant stood on the patient's right side.
3. Pneumoperitoneum was established using medical-grade CO₂ (purity ≥ 99.995%) at an initial pressure of 12 mmHg during trocar insertion to ensure adequate working space and was then reduced to 10 mmHg for maintenance throughout the procedure.

3. Trocar placement

1. A three-port technique was employed after intraoperative confirmation of the absence of major adhesions or edema in the gallbladder fossa (Calot's triangle region).
2. A 10-mm supraumbilical port was inserted using an open Hasson technique and served as the laparoscopic channel (Figure 2A, Table of Materials).
3. A 10-mm subxiphoid port was placed 2 cm below the xiphoid process along the midline as the main working port (Table of Materials).
4. A 5-mm port was placed at the left midclavicular line, 2 cm below the costal margin, for secondary instrument manipulation (Table of Materials).

4. Surgical procedure

1. The laparoscope was introduced to confirm situs inversus totalis and mirror-image anatomy, including a left-sided gallbladder, dominance of the left liver lobe, and a right-sided stomach (Figure 2B).
2. The gallbladder triangle was carefully dissected using a combination of blunt and sharp dissection. Owing to the mirrored anatomy, the surgical team frequently alternated dominant and non-dominant hands to adapt to the reversed orientation.
3. The serosal layers along both sides of the cystic duct were incised using an ultrasonic energy device (power setting 3, coagulation mode) to achieve skeletonisation and mobilisation of the cystic duct and to facilitate identification of the cystic vessels (Figure 3A).
4. A dissector was introduced with the left hand along the cystic duct to enter the plane between the cystic duct and the cystic artery, allowing clear visualisation of the common bile duct before clipping or transection (Figure 3B). This 'common bile duct first' approach reduced the risk of biliary injury.
5. The cystic duct was ligated using three medium Hem-o-lok clips, with two clips placed 5 mm from the common bile duct and one placed 3 mm from the gallbladder neck (Figure 3C). During this step, suboptimal angulation of the left-hand instrument caused minor periductal tissue injury with approximately 5 mL of bleeding, which was controlled using bipolar coagulation (power setting 20 W).
6. After transection of the cystic duct with laparoscopic scissors, the cystic artery was dissected and controlled using a Hem-o-lok clip applied with the left hand. Due to ergonomic limitations, the clip was placed approximately 2 mm from the gallbladder wall (Figure 3D). To reduce the risk of gallbladder perforation and bile leakage, a retrograde dissection strategy was adopted.
7. The ultrasonic energy device was operated with the left hand, whereas the right hand provided traction on the gallbladder fundus to expose the plane between the gallbladder and the liver bed (Figure 3E). The gallbladder was dissected retrogradely with sequential coagulation and division of peritoneal attachments.
8. An additional feeding vessel measuring approximately 2 mm in diameter, not arising from the main cystic artery and presumed to originate directly from the liver bed, was identified during retrograde dissection, clipped with a hem-o-lok clip and divided (Figure 3F).
9. After complete removal of the gallbladder, the operative field was inspected to confirm hemostasis and clear identification of all ductal structures (Figure 3G).
10. The gallbladder was retrieved through the supraumbilical port using an endobag. All ports were closed with absorbable sutures, and sterile dressings were applied. No drain was placed because intraoperative bleeding was minimal, and no bile leakage was observed.

The procedure lasted 75 min, with an estimated blood loss of 20 mL. No intraoperative complications occurred. Preoperative and postoperative clinical data were systematically collected to validate the protocol, including key indicators such as abdominal tenderness, laboratory test results, functional recovery status, and pain scores (Table 1).

The patient resumed oral intake and ambulation on postoperative day 1 and experienced mild abdominal pain (numeric rating scale score of 3), which was controlled with oral acetaminophen (500 mg every 6 h). She transitioned to a regular diet on postoperative day 2 and was discharged uneventfully on postoperative day 3. The decision to discharge on day 3, rather than the typical postoperative day 1 or 2 for standard laparoscopic cholecystectomy, was based on prophylactic observation due to the rare anatomical variant and the potential for delayed complications (e.g., subclinical biliary leakage or bleeding) in cases with mirrored anatomy. No postoperative complications, including infection, bile leakage, bleeding, or incisional hernia, were observed (Table 1).

Figure 1: Preoperative MRCP images confirming situs inversus totalis and gallbladder stones. (A) Coronal view showing left-sided gallbladder (a), left liver lobe (b), and right-sided stomach (c). (B) Axial view demonstrating gallbladder stones (a), left liver (b), and right-sided spleen (c). (C) Sagittal view of the left-sided biliary tree: gallbladder (a), common hepatic duct (b), cystic duct (c), common bile duct (d), right main pancreatic duct (e), and right-sided stomach (f). Arrows indicate gallbladder stones. Please click here to view a larger version of this figure.

Figure 2: Schematic diagram of puncture hole positioning and intraoperative mirror image anatomical structure view for three-port laparoscopic cholecystectomy. (A) Schematic diagram of puncture hole positioning. Arrow a indicates the 10 mm subxiphoid puncture hole (main operation hole, located 2 cm below the xiphoid process on the midline); Arrow b indicates the 5 mm left midclavicular line puncture hole (auxiliary operation hole, located 2 cm below the costal margin). (B) Intraoperative mirror image anatomical structure view. Arrow a indicates the left gallbladder; Arrow b indicates the cystic duct; Arrow c indicates the common bile duct; Arrow d indicates the right hepatic duct. Please click here to view a larger version of this figure.

Figure 3: Key intraoperative steps of three-port laparoscopic cholecystectomy in a patient with situs inversus totalis. (A) Skeletization of the cystic duct. The serosal layers on both sides of the cystic duct were incised using an ultrasonic energy device (power level 3, coagulation mode). Arrow a indicates the gallbladder; arrow b indicates the common bile duct; arrow c indicates the cystic duct; arrow d indicates the cystic artery. (B) Dissection of the space between the cystic duct and the cystic artery): Arrow a indicates the cystic duct; arrow b indicates the common bile duct; arrow c indicates the cystic artery. (C) Clamping of the cystic duct and cystic artery. Arrow a indicates the cystic duct (ligated with 3 medium-sized Hem-o-lok clips, 2 of which are 5 mm away from the common bile duct and 1 is 3mm away from the neck of the gallbladder); arrow b indicates the cystic artery; arrow c indicates minor bleeding from the surrounding tissue of the catheter (about 5 mL, controlled with bipolar electrocoagulation at 20 W power). (D) Detailed view of the clamping of the cystic artery. The Hem-o-lok clip is placed about 2 mm away from the gallbladder wall. (E) Retrograde dissection of the gallbladder. Retrograde dissection starts from the bottom of the gallbladder. Arrow a indicates the ultrasonic energy device (operated with the left hand); arrow b indicates the serosa of the gallbladder; arrow c indicates traction of the bottom of the gallbladder to expose the space between the gallbladder and the liver bed. (F) Identification and clamping of accessory blood vessels. Arrow a indicates an accessory blood vessel (about 2 mm in diameter, originating from the liver bed); arrow b indicates the Hem-o-lok clip (used to ligate the accessory blood vessel); arrow c indicates the liver tissue around the vessel. (G) Final surgical field after cholecystectomy. Arrow a indicates the gallbladder bed after hemostasis. (H) Comprehensive view of the surgical field after surgery. Arrow a indicates the stump of the cystic duct; arrow b indicates the common bile duct; arrow c indicates the stump of the cystic artery; arrow d indicates the severed accessory blood vessel. Please click here to view a larger version of this figure.

Table 1: Preoperative and postoperative clinical data of the patient with situs inversus totalis and gallbladder stones.

The success of laparoscopic cholecystectomy in situs inversus totalis relies on three critical protocolised steps. First, optimization of preoperative imaging with MRCP is essential to map mirrored anatomy and rule out biliary tract variants, as anatomical ambiguity increases the risk of injury⁸. Magnetic resonance cholangiopancreatography provides detailed visualisation of the left-sided gallbladder, cystic duct and common bile duct, which guided port placement and dissection strategy in this case⁹. Second, adaptations to patient positioning and surgical team orientation (reverse Trendelenburg with left-side elevation, screen on the patient's left and surgeon on the right) directly address the mirrored anatomy, improving visualisation and reducing instrument collision. This represents a key advantage over standard positioning, which would result in suboptimal exposure¹⁰. Third, early identification of the common bile duct is a cornerstone of the protocol. By prioritising localization of the common bile duct before manipulation of the cystic duct or artery, the risk of biliary injury, a major complication in situs inversus totalis cases, is minimized¹¹. This step, combined with sequential skeletonisation of the cystic duct, ensures clear anatomical delineation even in reversed anatomy.

Several modifications to standard laparoscopic cholecystectomy were implemented to address challenges specific to situs inversus totalis. A three-port approach was selected instead of the conventional four-port technique because no intra-abdominal adhesions or edema were identified intraoperatively. Although four-port approaches are often recommended for complex cases to improve triangulation^12,13, the three-port modification reduces invasiveness, shortens skin-to-skin time, and decreases postoperative pain, consistent with the minimal blood loss (20 mL) and rapid postoperative ambulation observed in this case¹⁴. Troubleshooting during the procedure included switching between dominant and non-dominant hands to adapt to reversed anatomy, which resolved ergonomic challenges related to instrument angulation. When initial clipping of the cystic artery was suboptimal because the clip was placed too close to the gallbladder, the protocol included a predefined switch to retrograde dissection, thereby avoiding gallbladder perforation. Minor periductal bleeding was successfully controlled with bipolar coagulation, underscoring the importance of familiarity with alternative hemostatic techniques when operating in mirrored anatomy.

Despite the favourable outcome, this protocol has several limitations. First, the three-port approach may not be universally applicable. Patients with dense intra-abdominal adhesions, acute cholecystitis with severe edema, or associated biliary tract anomalies may require a four-port approach to improve visualisation and manoeuvrability¹⁵. Second, successful implementation of the protocol relies heavily on surgeon expertise in hepatobiliary surgery, and less experienced surgeons may benefit from additional ports or intraoperative cholangiography (IOC) to reduce the risk of error. Third, an IOC was not performed in this case, which may be considered a limitation. Although preoperative MRCP excluded biliary tract variants, IOC provides real-time anatomical confirmation and may further reduce the risk of biliary injury in high-complexity cases¹⁵. However, IOC increases operative time and radiation exposure, and its utility in situs inversus totalis remains debated¹⁶. In the present case, early identification of the common bile duct combined with sequential skeletonisation of the cystic duct provided sufficient anatomical clarity. Finally, the protocol is based on a single case, and larger cohort studies are required to validate its generalisability.

This protocol offers several advantages compared with existing approaches to laparoscopic cholecystectomy in situs inversus totalis. Relative to open cholecystectomy, which has historically been used for anatomical variants⁶, the three-port minimally invasive technique reduces postoperative pain, shortens recovery time, and lowers the risk of wound complications, as demonstrated by the patient's rapid return to oral intake and ambulation. Compared with four-port laparoscopic techniques¹⁶, the three-port modification maintains surgical efficacy while minimizing invasiveness, supported by the absence of postoperative complications and sustained recovery at 1 year. In addition, the protocol emphasises integration of preoperative imaging and intraoperative adaptability, addressing gaps in existing literature that frequently lack detailed technical guidance for mirrored anatomy^17,18,19. By standardizing key steps, such as patient positioning, port placement, and early common bile duct identification, the protocol reduces reliance on surgeon intuition and improves reproducibility for teams managing rare situs inversus totalis cases. This approach facilitated safe mobilisation of the cystic duct and adequate exposure of Calot's triangle, allowing reliable identification and isolation of the cystic artery.

This protocol has potential applications in minimally invasive surgery for rare anatomical variants. First, it may be adapted for other biliary procedures, such as laparoscopic common bile duct exploration, in patients with situs inversus totalis, as reported in recent case series¹¹. Second, the principles of mirrored anatomy adaptation, including positioning adjustments, hand switching and predefined troubleshooting strategies, may be extended to other abdominal procedures, such as colectomy or appendectomy, in patients with situs inversus²⁰. Third, the protocol may inform training programs for minimally invasive surgeons by providing a structured framework for managing anatomical anomalies. Future studies should focus on prospective cohort comparisons of three-port versus four-port techniques in situs inversus totalis and on further evaluation of the role of IOC in this population. Integration of this protocol into surgical decision-making algorithms may contribute to more standardized and safer care across institutions.