Question

It is night in a small rural hospital, as the on-call surgeon you are suggested to put a chest tube for a pleural effusion. The Chest x-ray done by a radiologist technician is suggestive for a right pleural effusion (Figure 1). Examining the patient it sounds like a left pleural effusion and heartbeat is strongest on the right. You do a quick bedside scan: left side effusion, dextrocardia, abdominal viscera are inverted. CXR is repeated, this time putting a marker on the right side (Figure 2). Which side do you place the tube? and what is this rare anatomic anomaly that presented?

Answer

Chest tube is put on the patients left because of Situs inversus totalis, a rare condition where the cardiac atria and the abdominal viscera are the mirror image of normal presentation. Hence these patients present with dextrocardia, the liver and gallbladder are located on the left, whereas the spleen and stomach are located on the right. The remaining internal structures are also a mirror image of the normal. Most importantly always examine your patients!