A rare anatomical variation complicating a diffuse abdominal pain presentation: A case report of colonic perforation in situs inversus totalis

INTRODUCTION: Situs inversus totalis (SIT) is a rare anatomical variation of the thoracic and abdominal organs. It is a congenital anomaly with an incidence of 1:10,000 to 1:20,000. Patients with SIT do not have a decreased survival rate as compared to patients without SIT because SIT generally does not have a pathophysiologic significance. However, the anatomical variations in SIT can cause some challenges when assessing intraabdominal and intrathoracic symptoms or performing operations. CASE PRESENTATION: We report a case of a 93-year-old woman with a past medical history of hypertension, hyperlipidemia, atrial fibrillation, and situs inversus totalis who presented with diffuse abdominal pain for 4 days. Abdominal exam was significant for diffuse tenderness. Computed tomography (CT) imaging was significant for pneumoperitoneum. She emergently underwent an exploratory laparotomy, descending hemicolectomy and left in discontinuity with an open abdomen. On postoperative day 2 she underwent a stamm feeding gastrostomy tube, incisional hernia repair, and maturation of end colostomy. Her remaining hospital course was complicated by a pelvic collection, which was managed by a percutaneous guided drain placement. She was ultimately discharge to rehab on hospital day 15. DISCUSSION: SITS can present a particularly challenging situation to clinical diagnoses and surgical procedures. However, when identified, these patients should warrant special considerations prior to proceeding with surgical intervention. This includes radiologic imaging and proper planning prior to the operating room, when possible. CONCLUSION: We herein present a case of colonic perforation in a patient with situs inversus totalis. Proper planning, thorough imaging, and careful execution are necessary to ensure patient safety and care in patients with SIT. However, in the case of emergency this should not delay definitive management.