Safe Laparoscopic Cholecystectomy in Mirror-Image Anatomy: Acute Biliary Pancreatitis and Acute Calculous Cholecystitis in Situs Inversus Totalis.

Situs inversus totalis (SIT) is a rare congenital laterality anomaly characterized by the complete mirror-image transposition of the thoracic and abdominal viscera. Although it is usually asymptomatic, the occurrence of acute biliary disease poses significant diagnostic and surgical challenges because the atypical location of pain and reversed anatomy may complicate clinical assessment, interpretation of imaging studies, and laparoscopic planning. We present the case of a patient with acute biliary pancreatitis associated with acute calculous cholecystitis in the setting of SIT, whose management required individualized diagnostic evaluation and surgical planning tailored to the mirror-image anatomy. A 20-year-old woman with a known diagnosis of SIT presented with a three-day history of severe epigastric pain radiating to the left upper quadrant and back, accompanied by nausea and vomiting. Laboratory evaluation demonstrated markedly elevated pancreatic enzyme levels, mild hyperbilirubinemia, and elevated liver transaminases. Abdominal ultrasonography revealed cholelithiasis and findings suggestive of SIT. Contrast-enhanced computed tomography confirmed dextrocardia, complete visceral transposition, acute pancreatitis with peripancreatic inflammatory changes, and imaging findings consistent with acute calculous cholecystitis without biliary ductal dilatation. Based on the Revised Atlanta Classification, the patient was diagnosed with mild acute biliary pancreatitis. Following clinical stabilization, laparoscopic cholecystectomy was successfully performed using a mirror-image trocar configuration adapted from the conventional technique. The postoperative course was uneventful, and histopathological examination confirmed chronic cholecystitis associated with cholelithiasis. SIT is not a contraindication to laparoscopic cholecystectomy in patients with acute biliary disease; however, it requires early recognition of the mirror-image anatomy, accurate interpretation of imaging findings, and individualized surgical planning. In this setting, mirror-image trocar placement and strict adherence to the critical view of safety are essential to minimize the risk of bile duct injury. This case demonstrates that, with meticulous preoperative anatomical assessment and an individualized surgical strategy, laparoscopic management can be performed safely and effectively.