Anesthesia management for laparoscopic cholecystectomy and choledochoscopy-assisted intrahepatic bile duct stone extraction in a patient with situs inversus totalis, decompensated cirrhosis, and respiratory insufficiency: a case report

Situs inversus totalis (SIT) is a rare congenital anatomical anomaly characterized by mirror-image reversal of thoracic and abdominal organs. Perioperative management becomes particularly challenging when SIT coexists with inferior vena cava (IVC) malformation (e.g., agenesis of the hepatic segment), decompensated cirrhosis, and respiratory insufficiency—a complex scenario for which relevant anesthesia experience is exceedingly limited.

A 66-year-old female patient with SIT complicated by polysplenia syndrome and agenesis of the hepatic segment of the IVC presented for surgical management of intrahepatic bile duct stones, cholangitis, and obstructive jaundice. Preoperatively, she had Child-Pugh C cirrhosis and respiratory insufficiency. The patient underwent laparoscopic cholecystectomy, choledochoscopic-assisted intrahepatic bile duct stone extraction, and T-tube drainage. The anesthesia strategy comprised mirror-image ECG lead placement, transthoracic echocardiography (TTE) -guided preload assessment utilizing left ventricular end-diastolic area with subsequent optimization of fluid therapy, preferential selection of hepatically non-metabolized drugs, and employing lung-protective ventilation with permissive hypercapnia targeting PaCO₂ ≤ 65 mmHg. The procedure lasted 320 min with stable hemodynamics. The patient was transferred to the intensive care unit (ICU) with the endotracheal tube in situ and was successfully extubated 1 h after admission. She was discharged from the ICU on postoperative day 6, showing improvement in liver function and overall clinical status compared with her preoperative baseline.

To our knowledge, this is the first description of anesthesia management for a patient with SIT complicated by Child-Pugh C cirrhosis and respiratory insufficiency, highlighting TTE as an alternative for preload monitoring in the presence of IVC anomalies. Anticipation of anatomical variations and implementation of an individualized anesthesia strategy are critical to ensuring perioperative safety.