A case report of Mirizzi syndrome type II in a patient with situs inversus totalis treated with laparoscopic cholecystectomy.

Introduction: Situs inversus totalis (SIT) is a rare congenital condition characterized by complete mirror-image transposition of the thoracic and abdominal organs. Mirizzi syndrome is an uncommon complication of cholelithiasis that can substantially increase the technical difficulty of cholecystectomy. Importance: The coexistence of SIT and Mirizzi syndrome is exceedingly rare and presents unique challenges related to altered anatomy, operative orientation, and surgical ergonomics. Case presentation: A 30-year-old man with SIT, Kartagener syndrome, Hirschsprung disease, chronic obstructive pulmonary disease, pre-hypertension, and primary biliary dyskinesia presented with worsening abdominal pain despite prior biliary stent placement. Magnetic resonance cholangiopancreatography demonstrated cholelithiasis with an impacted gallstone at the gallbladder neck, consistent with Mirizzi syndrome, gallbladder distention, biliary ductal dilation, and a low medial insertion of the cystic duct. Laparoscopic cholecystectomy was performed using mirrored port placement, with the surgeon positioned on the right side of the patient. Intraoperatively, an aberrant left hepatic artery was found in close association with the cystic duct and gallbladder, preventing safe attainment of the critical view of safety. A dome-down approach was therefore used to complete the operation safely. The patient recovered without complications. Clinical discussion: Published reports and a meta-analysis of laparoscopic cholecystectomy in patients with SIT demonstrate that minimally invasive management is feasible and safe despite the challenges posed by mirrored anatomy, altered ergonomics, and anatomic variation. Conclusion: Preoperative imaging, mirrored port placement, and alternative dissection strategies, such as the dome-down approach, may facilitate safe laparoscopic management of Mirizzi syndrome in patients with SIT.