B. B. Likhitha, Niranjan Hiremath
Situs inversus totalis (SIT) is an uncommon congenital autosomal recessive condition in which the thoracic and abdominal viscera are arranged as a mirror image of normal anatomy. Although SIT is generally an incidental and asymptomatic finding that does not affect life expectancy, it creates substantial anatomical and spatial challenges for safe surgical and anaesthetic management. We report the surgical management of a symptomatic enlarging intramural uterine fibroid with a concomitant left ovarian haemorrhagic cyst in a 36-year-old woman (gravida 3, para 3) with SIT, dextrocardia, and a right-sided aortic arch. The patient underwent total abdominal hysterectomy, bilateral salpingectomy, and left oophorectomy through a suprapubic transverse incision under combined spinal-epidural anaesthesia. The reversed pelvic anatomy required deliberate adjustment of the surgeon's right-left orientation and modification of the usual operative sequence. Intraoperatively, the surgical team carefully identified, exposed, skeletonised, divided, and ligated the pelvic vessels and uterine ligaments while preserving surrounding tissue integrity. Meticulous multidisciplinary preoperative assessment included two-dimensional echocardiography, which demonstrated concentric left ventricular hypertrophy, a left ventricular ejection fraction of 60%, and no regional wall-motion abnormality. The postoperative course was uneventful. Precise preoperative evaluation, careful documentation, multidisciplinary planning, and intraoperative spatial readjustment were central to the overall successful surgical outcome.