Laparoscopic cholecystectomy in situs inversus totalis: a case report

A 32 year old female presented to our department with epigastric pain radiating through to the back. A diagnosis of acute cholecystitis in a patient with situs inversus totalis was made following clinical examination and radiological investigation. Laparoscopic cholecystectomy was subsequently performed and the patient made an uneventful recovery.Situs inversus presenting with acute cholecystitis is very rare. The surgeon must appreciate that care should be taken to set up the operating theatre in the mirror image of the normal set-up for cholecystectomy, and that right handed surgeons must modify their technique to adapt to the mirror image anatomy.In 1600 the first known case of situs inversus in humans was reported by Fabricius [1]. The incidence is thought to be in the region of 1:5000 to 1:20000 [2]. The condition may affect the thoracic organs, abdominal organs or both. It is associated with a number of other conditions such as Kartagener's (bronchiectasis, sinusitis, situs inversus) and cardiac anomalies. There is no current evidence that situs inversus predisposes to cholelithiasis [3].Since Mouret first performed it in 1987, laparoscopic cholecystectomy has become the standard operative procedure for gallbladder disease. It is associated with reduced hospital stay, fewer respiratory complications, less pain and a faster return to work.A thirty two year old female was admitted with a three hour history of epigastric pain radiating into her back in keeping with biliary colic. She had vomited a number of times. In the previous week she had two episodes of a similar nature.On examination there was no jaundice or pyrexia. The apex beat was in the right fifth intercostal space, midclavicular line. She had epigastric tenderness but was not tender in the right or left upper quadrants. Her white cell count and amylase level was normal but her C-reactive protein level (CRP) was elevated at 290 mg/L. An electrocardiograph showed right axis deviation and right ventricu