Background : Situs inversus totalis is a rare congenital disease characterised by complete right to left inversion of all internal organs. Incidence is approximately 1 in 10,000. Exact etiology is unknown but Autosomal recessive and X – linked inheritance have been proposed. Due to altered anatomical position of vessels and organs, dissection and surgical resection is technically challenging

Methods : This is a case of 77y old man with situs inversus totalis with incidental carcinoma gall bladder detected after laparoscopic cholecystectomy done elsewhere, histopathology showed p T2, Moderately differentiated Adenocarcinoma with perineural invasion. PET scan done 4 weeks later showed situs inversus totalis, hypo-density infiltrating segment IVB at post-operative site with SUV 4.38. Tumor markers are normal. In view of residual disease, he is given 4# Gemcitabine + Oxaliplatin. Revision cholecystectomy is performed 5 weeks after neoadjuvant chemotherapy

Results : The total operative time is 180min with a blood loss of 400ml. He had early division of common hepatic artery and right hepatic artery coursing posterior to portal vein which is demonstrated in the video. Post-operative period is uneventful. Histopathology revealed no residual disease, 0/22 Lymph nodes. Final stage- p T2N0, Stage II.

Conclusions : Careful consideration of the mirror image anatomy permitted a safe surgery using techniques not otherwise different from those used for general population. Surgery can be safely performed by paying attention to inverted anatomic structures during operation and pre-operative recognition of anatomic variations on imaging