Paradoxical pain localization and mirror-image laparoscopic cholecystectomy in situs inversus totalis: a case report and literature review
- 1Department of General Surgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- 2Department of General Surgery, Loghman Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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.
Related
- Development and Internal Validation of a Preoperative Risk Stratification Model for Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis
- Association of Serum Ferritin and Cytokine Profile With Severity of Acute Cholecystitis in Patients Undergoing Laparoscopic Cholecystectomy
- Tip perfusion index for monitoring perioperative stress responses in patients undergoing laparoscopic cholecystectomy: a prospective cohort study
- Early Laparoscopic Cholecystectomy for Acute Gallstone Pancreatitis: Retrospective Review of Factors Influencing Timing of Surgery and Outcomes in a Single Institution
- Optimizing Indocyanine Green Fluorescence Cholangiography in Laparoscopic Cholecystectomy: A Systematic Review of Randomized Controlled Trials on Dose, Timing, Route, Efficacy, and Safety
BibTeX
@article{mahmoodi2026paradoxical,
title = {{Paradoxical pain localization and mirror-image laparoscopic cholecystectomy in situs inversus totalis: a case report and literature review}},
author = {Setareh Mahmoodi and Mehra Fekri and Koosha Sami and Milad Dodangeh},
journal = {International Journal of Surgery Case Reports},
year = {2026},
month = oct,
doi = {10.1097/rc9.0000000000001151},
url = {https://doi.org/10.1097/rc9.0000000000001151},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Paradoxical pain localization and mirror-image laparoscopic cholecystectomy in situs inversus totalis: a case report and literature review
AU - Setareh Mahmoodi
AU - Mehra Fekri
AU - Koosha Sami
AU - Milad Dodangeh
PY - 2026
DA - 2026/10/22
JO - International Journal of Surgery Case Reports
DO - 10.1097/rc9.0000000000001151
UR - https://doi.org/10.1097/rc9.0000000000001151
AB - 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.
SN - 2210-2612
ER -