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Paradoxical pain localization and mirror-image laparoscopic cholecystectomy in situs inversus totalis: a case report and literature review

Year: 2026

Type: article

Abstract: Background: Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete mirror-image transposition of the thoracic and abdominal organs. Although laparoscopic cholecystectomy is the standard treatment for symptomatic gallstone disease, reversed anatomy creates unique diagnostic and technical challenges for both surgeons and radiologists. An even less common phenomenon is paradoxical right upper quadrant (RUQ) pain despite a left-sided gallbladder, which may delay diagnosis by masking biliary disease behind an apparently normal pain pattern. Case presentation: A 48-year-old Persian woman presented with a 2-day history of progressively worsening RUQ pain. Physical examination demonstrated localized tenderness without generalized peritonitis. Routine electrocardiography unexpectedly revealed dextrocardia, prompting further radiologic investigation. Abdominal ultrasonography demonstrated multiple gallstones within a left-sided gallbladder, while contrast-enhanced computed tomography confirmed complete SIT. After comprehensive preoperative cardiologic and anesthetic assessment, laparoscopic cholecystectomy was successfully performed using a mirror-image operating room configuration and reversed trocar placement. Despite altered anatomical orientation and ergonomic challenges, the critical view of safety was achieved before clipping and division of the cystic duct and artery. Histopathological examination confirmed chronic calculous cholecystitis. Recovery was uneventful, and the patient remained symptom-free at 6-month follow-up. Conclusion: This case highlights that the principal challenge in SIT extends beyond mirror-image anatomy to include paradoxical symptom localization and altered operative ergonomics. Recognition of laterality disorders, comprehensive preoperative imaging, and meticulous ergonomic adaptation allow laparoscopic cholecystectomy to be performed safely while maintaining the same fundamental surgical principles applied to patients with normal anatomy.

Source: International Journal of Surgery Case Reports

DOI: 10.1097/rc9.0000000000001151

Authors: Setareh Mahmoodi, Mehra Fekri, Koosha Sami, Milad Dodangeh

Institutions: Shahid Beheshti University, Shahid Beheshti University of Medical Sciences

Language: English

Topic: Gallbladder and Bile Duct Disorders

Subfield: Gastroenterology

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: gold

Estimated APC paid: $2,090