Situs Inversus Totalis with Cholelithiasis Managed by Open Cholecystectomy: A Case Report

Introduction: Situs inversus totalis (SIT) is a rare congenital anomaly where the thoracic and abdominal organs are transposed. Reversed hepatobiliary anatomy can result in nonclassical symptoms and creating problems in diagnosis and increasing technical complexity of cholecystectomy. Case Presentation The case of a 33-year-old female patient was presented with gradually increasing pain in the left hypochondrium, accompanied by nausea without vomiting and without clinical evidence of peritoneal irritation. A physical examination showed that the left hypochondrium was tender to palpation and that a left-sided Murphy sign was positive. Laboratory studies were in normal range, such as renal study, coagulation studies and the pancreatic profile. Ultrasonography revealed a left-sided liver and a gallbladder with calculi, with a wall thickness of 3 mm. An open cholecystectomy was done using an incision of about 7 cm in the supraumbilical midline. The left liver and gallbladder were verified by operative exploration. The gallbladder was part intrahepatic, 4 x 5 x 6 cm, thick-walled, and had one calculus; the appearance of the operative specimen was graded as Parkland III. The cystic duct and cystic artery were identified, ligated and divided without any intraoperative complications by carefully dissecting the triangle of the reversed Calot. Conclusion:During cholecystectomy in patients with SIT, it is important to have tested the reversed hepatobiliary anatomy and to be mindful of the cystic duct and the cystic artery. One size does not fit all; anatomical findings should be used to plan surgery, not vice versa.