CASE REPORT PATHOLOGY/BIOLOGY Figen Turk, 1 M.D.; Gökhan Yuncu, M.D.; Gökhan Ozturk, 1 M.D.; Yasin Ekinci, 1 M.D. and Tolga Semerkant, 1 M.D. Total Situs Inversus Found Coincidentally Following a Firearm Injury ABSTRACT: Situs inversus totalis is very rare and usually diagnosed coincidentally as it does not affect the patient’s life. Being unaware of the patient’s condition can lead to undesirable results from the surgeon and patient’s point of view when an emergency and forensic surgical intervention is required. We present a case who was operated on urgently for a firearm injury after receiving a preoperative diagnosis of situs inversus totalis. In conclusion, situs inversus totalis can cause difficulties for surgeons in case of emergency surgery and is usually diagnosed coincidentally. There are a few cases of situs inversus with lung cancer in the literature but this is the first time a case with a firearm injury has been reported. KEYWORDS: firearm injury, situs inversus totalis, hemopneumothorax, forensic, emergency, surgery Situs inversus totalis refers to a perfect mirror image of the normal physiological positions of the thoracic and abdominal visceral organs with preservation of anteroposterior relationships. It is a very uncommon entity and was first reported by Fabricius in 1600 (1). The incidence is thought to be in the range of 1:10,000 to 1:20,000 (2). Situs inversus totalis does not affect the normal life of the patient, and the diagnosis is usually coinci- dental. However, acute traumatic and forensic problems, acute appendicitis, and other disorders requiring acute intervention can lead to surprises for the surgeon and patient if the condition is not recognized preoperatively (3–5). We present a patient who suffered a firearm injury and was brought to our emergency ser- vice by ambulance where situs inversus was found on preopera- tive X-rays and review the relevant literature. Case Report A 27-year-old man married with one child had been shot from a distance of approximately 1.5 meters with a hunting rifle and brought to our emergency service by ambulance within 20 min with IV access secured and a dressing applied over the injured area. The patient was pale and in poor general condition. His blood pressure was 70/40 mm Hg and the pulse 125/min. The lung sounds had decreased on the right. The portable PA chest X-ray at the emergency service revealed multiple rib fractures and multiple gunshot pellets in addition to dextrocardia and a right-sided gastric fundus. The patient’s condition deteriorated and he was taken for surgery after a drain was applied and intu- bation performed. Inspection revealed a 7-cm open wound on the anterior aspect of the right hemithorax from which a comminuted fracture of the sixth, seventh, and eighth ribs and injury of the muscles could be observed. There was drainage of copious amounts of hemorrhagic fluid from the thorax. Right thoracotomy was performed and exploration revealed two lobes, a single fissure, and a lingular segment of the right lobe. Primary repair and bleeding control was used for the 12-cm parenchymal damage in the lower lobe. The comminuted fractures of the ribs and lacerated muscles were explored and some of the gunshot pellets were removed. Five units of erythrocyte suspension were infused for hemodynamic support. Postoperative early follow-up X-ray revealed that the lungs had expanded but some of the gun- shot pellets were still present (Fig. 1). The patient had severe abdominal pain on the first postoperative day. Abdominal CT revealed that the stomach and spleen were on the right and the liver on the left with no additional pathology (Fig. 2). The mid- gut is also reversed with cecum and appendix located on left lower quadrant. The patient tolerated oral feeding on postopera- tive day 2, the drain was removed on day 5, and he was dis- charged on day 8. Echocardiography on day 15 follow-up revealed an ejection fraction of 76% and no cardiac pathology other than total situs inversus. Discussion Heart and major vessel damage is the most common cause of death in thoracic injuries owing to firearms. The lungs show sig- nificant resistance to a temporary cavitation effect thanks to their alveolar structure surrounded by strong connective tissue and the multiple air sacs that are poor conductors of kinetic energy. Lung injuries owing to guns or hunting rifles (firearms with moderate energy and moderate speed; range, 250–400 m/sec) can therefore be treated with primary repair and thoracic drainage 80–90% of the time when there is no fatal heart, major vascular structure, or main bronchus damage (6–8). The injury was in the right hemitho- 1 Department of Thoracic Surgery, Pamukkale University Faculty of Medi- cine, 20.070, Kinikli, Erenler Mah. 211.Sok No: 4B/4, Denizli, 20055, Turkey. Received 22 July 2011; and in revised form 13 Oct. 2011; accepted 23 Oct. 2011. © 2012 American Academy of Forensic Sciences 1 J Forensic Sci, 2012 doi: 10.1111/j.1556-4029.2012.02256.x Available online at: onlinelibrary.wiley.com