We conclude that major thoracic procedure can be safely performed under awake anaesthesia. The technique avoids general anaesthesia and endotracheal intubation, reduces postoperative hospital stay and minimizes intensive care unit admission. This study strongly suggests awake anaesthesia can improve outcomes and reduce cost. A proper multi-center trial to further evaluate this technique is needed.

Patient: Female, 68Final Diagnosis: Gallbladder agenesis with situs inversus totalisSymptoms: Epigastric pain • jaundiceMedication: —Clinical Procedure: —Specialty: SurgeryObjective:Rare diseaseBackground:Situs inversus totalis is an inherited condition characterized by the mirror-image transposition of thoracic and abdominal organs. Gallbladder agenesis, which has normal bile ducts, is a rare congenital condition that occurs in 13 to 65 people out of 100 000. A common bile duct (CBD) stone or choledocholithiasis in patients with gallbladder agenesis is even rarer.Case Report:We report the case of a 68-year-old woman who presented with epigastric pain and jaundice. She was not known to have situs inversus totalis. Abdominal ultrasound showed a large stone in the CBD, which could not be extracted by endoscopic retrograde cholangiopancreatography (ERCP), necessitating exploration. The gall-bladder and cystic duct were found to be absent. Incisional exploration of the CBD was performed, and a large stone was removed. A choledochoscope was used to identify the remnants and exclude the presence of ectopic gallbladder, and a T-tube was placed into the CBD.Conclusions:Gallbladder agenesis in a patient with situs inversus totalis is extremely rare, with no single reported case identified in the literature. In addition, our case showed a rare complication of ERCP – a failure to extract the CBD stone – and illustrates a way to overcome this complication.

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