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

Summary

We present a protocol for three-port laparoscopic cholecystectomy in patients with situs inversus totalis and gallbladder stones, detailing preoperative imaging optimization, mirrored anatomy adaptations, and intraoperative safety strategies to achieve successful minimally invasive treatment.

Abstract

Situs inversus totalis, also known as mirror man, is an extremely rare anatomical variant in which the positions of the thoracic and abdominal organs are reversed. This case is novel due to the combination of situs inversus totalis and gallbladder stones, presenting unique surgical challenges. Reporting this case underscores the importance of preoperative imaging and surgical technique adjustments for achieving a successful laparoscopic cholecystectomy in such rare anatomical variants. A 58-year-old female patient presented with recurrent left-sided low back pain for over 2 months, exacerbated in the previous 2 days. She had no major medical history. Imaging revealed gallbladder stones with situs inversus totalis. Preoperative evaluation included comprehensive imaging to assess biliary tract variations. Laparoscopic cholecystectomy was performed using a three-port approach, with careful adjustments for the mirrored anatomy. The operation was successful, with minimal intraoperative bleeding (20 mL) and no complications. The patient recovered well, started eating and mobilising on the first postoperative day and was discharged on the third day. Follow-up at 3 months showed no considerable discomfort, and a 1-year telephone follow-up confirmed sustained recovery. This case highlights the importance of thorough preoperative imaging and surgical planning in managing patients with situs inversus totalis. The successful laparoscopic cholecystectomy demonstrates that, with careful preparation and technique adjustments, minimally invasive surgery can be safely performed even in rare anatomical variants. This experience provides valuable insights for surgical teams encountering similar cases, emphasising the need for meticulous preoperative assessment and intraoperative adaptability.

Introduction

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.

Protocol

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.

Results

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 o...

Discussion

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 cas...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Anesthesia machine	Datex-Ohmeda	Aisys CS2 (https://www.gehealthcare.com)	General anesthesia system
Energy device	Ethicon	GEN11 (https://www.ethicon.com)	Ultrasonic dissecting device
Hem-o-lok clips	Teleflex	HCL-35 (https://www.teleflex.com)	Medium vascular clips
Laparoscope	Karl Storz	301230 (https://www.karlstorz.com)	10 mm 30° rigid laparoscope
Laparoscopic dissector	Karl Storz	341610 (https://www.karlstorz.com)	Curved dissecting forceps
Pneumoperitoneum insufflator	Karl Storz	264300 (https://www.karlstorz.com)	CO? insufflator with pressure monitoring
Trocar	Ethicon	4205210 (https://www.ethicon.com)	10 mm supraumbilical trocar
Trocar	Ethicon	4205210 (https://www.ethicon.com)	10 mm subxiphoid trocar
Trocar	Ethicon	4205150 (https://www.ethicon.com)	5 mm left midclavicular line trocar