# Situs Inversus Totalis: Challenges and Anatomical Considerations in Endoscopic Retrograde Cholangiopancreatography

## TL;DR

This paper discusses the challenges of performing ERCP in a patient with reversed internal organs and how adjustments helped achieve successful treatment.

## Contribution

The paper presents a novel case of ERCP in SIT with specific procedural adaptations for successful cannulation.

## Key findings

- ERCP in SIT requires positional and scope adjustments to navigate reversed anatomy.
- Successful biliary drainage was achieved using a prone position and 360-degree scope rotation.
- Clinical improvement was observed, enabling subsequent surgical intervention.

## Abstract

Situs inversus totalis (SIT) is a rare condition characterised by the reversed positioning of abdominal and thoracic viscera. The anomaly poses a significant anatomical challenge during routine endoscopic procedures, including endoscopic retrograde cholangiopancreatography (ERCP). Here, we present the case of a 51-year-old patient with SIT and obstructive jaundice due to a periampullary mass. Initial ERCP attempts at an external facility for biliary decompression were unsuccessful, prompting referral to our center. Multidisciplinary consensus recommended preoperative ERCP followed by a Whipple’s procedure. ERCP was performed with positional adjustments (prone position) of the patient and significant scope manipulation (stepwise 360-degree anticlockwise rotation) to navigate the reversed anatomy. Cannulation was achieved, and a plastic biliary stent was placed, resulting in effective drainage. The patient demonstrated clinical improvement and was referred for surgical intervention. A comprehensive understanding of the reversed anatomy, along with the operator's skill and experience, is essential to address the challenges posed by this unique anatomical variation.