Fluorescence-guided laparoscopic cholecystectomy with concurrent mayo's repair in an hiv-positive patient with situs inversustotalis: a rare case report

Background: Situs inversustotalis (SIT) is a rare congenital anomaly characterized by complete right-to-left transposition of thoracic and abdominal viscera, occurring in approximately 1 in 10,000–25,000 live births. Although the condition itself is usually asymptomatic, surgical intervention becomes technically demanding because of mirror-image anatomy. Laparoscopic cholecystectomy remains the gold standard treatment for symptomatic cholelithiasis; however, altered orientation requires modifications in operative strategy and surgeon ergonomics. The coexistence of Human Immunodeficiency Virus (HIV) infection, previous abdominal surgery, incisional hernia, and extensive intra-abdominal adhesions further increases operative complexity. Case Presentation: A 44-year-old HIV-positive female presented with left hypochondriac pain for four days. She had a history of hypertension, pulmonary tuberculosis (treated), poor compliance with antiretroviral therapy, and paraumbilical incisional hernia following tubal ligation performed 15 years earlier. Ultrasonography and Magnetic Resonance Cholangiopancreatography (MRCP) demonstrated cholelithiasis with situs inversustotalis. The patient underwent fluorescence-guided laparoscopic cholecystectomy with simultaneous Mayo's repair of the incisional hernia. Dense intra-abdominal adhesions were encountered and carefully divided using a harmonic scalpel. Intraoperative Indocyanine Green (ICG) fluorescence cholangiography facilitated identification of the cystic duct and cystic artery in mirror-image anatomy. Following achievement of the Critical View of Safety, the cystic duct and artery were clipped and divided, and laparoscopic cholecystectomy was completed successfully without bile duct injury or conversion to open surgery. The postoperative course was uneventful, and the patient was discharged on postoperative day two. Conclusion: Laparoscopic cholecystectomy in situs inversustotalis is technically demanding but can be safely performed with meticulous preoperative planning, ergonomic modifications, and adherence to the Critical View of Safety. Fluorescence-guided biliary imaging further enhances anatomical orientation and may reduce the risk of bile duct injury in complex cases.