Laparoscopic cholecystectomy is the standard operative procedure for gallbladder disease and is the most commonly performed general surgery procedure worldwide [8]. Over the last three decades, extensive efforts have been made to optimize outcomes and minimize complications, particularly iatrogenic bile duct injuries (BDI) that continue to be the primary concern after gallbladder surgery [7]. Perhaps one of the most widely accepted approaches is the identification of the Critical View of Safety (CVS), as described by Strasberg et al. [9] and the selective use of intraoperative cholangiogram [10].

The reported incidence of iatrogenic BDI in patients undergoing laparoscopic cholecystectomy ranges between 0.07 and 1.1 % in the literature [11,12]. While there is no evidence to suggest that SIT increases the risk of BDI following laparoscopic cholecystectomy [13], the anatomical variation associated with SIT is a potential risk factor that may contribute to a higher incidence of BDI after the procedure [14,15]. Furthermore, several other factors may contribute to an increased risk of BDI in patients with SIT:

• 1.A delay in the diagnosis and management of gallbladder disease can occur if the patient's SIT status is unknown beforehand [3]. This delay may result from the atypical presentation of LUQ pain, which can sometimes be confused with pancreatitis [4].
• 2.Currently, there is no standardized technique for the optimal management of gallbladder disease in patients with SIT [3]. However, some techniques have been proposed to reduce the risk of BDI after laparoscopic cholecystectomy, which can be employed [14].
• 3.The reversed anatomy in patients with SIT presents a challenge for right-handed surgeons, while left-handed surgeons may have an advantage.

In patients with SIT, laparoscopic surgery represents a significant challenge for the operating surgeon and the operating room team in various aspects. The team should be ready to perform a mirror-image procedure at all levels, considering the target organ's new mirror-image position within the abdominal or thoracic cavity; this involves adjusting the positions of the surgeon, assistants, and the monitor, as well as repositioning trocars and instruments, taking into account the anatomical variations common in patients with SIT [16].

The surgeon must also reorient his surgical skills to the LUQ during cholecystectomy. All of these factors contribute to the complexity of the case, requiring the surgeon to overcome the influence of habitual thinking in his operative techniques for commonly performed laparoscopic procedures to avoid complications and achieve successful outcomes [16]. The complexity is further amplified during acute surgical conditions because the surgeon will not have the luxury of time to mentally prepare for such challenging situations that demand extensive surgical modifications.

The first successful laparoscopic cholecystectomy in a patient with SIT was performed in 1991 by Campos and Sipes [17]. Since then, more than 90 cases of successful laparoscopic cholecystectomy in patients with SIT have been reported [3]. Additionally, multiple reports have demonstrated the successful utilization of laparoscopic surgery in patients with SIT for various surgical operations [[18], [19], [20]].

In a recent systematic review of laparoscopic cholecystectomy in SIT, Chaouch et al. identified 93 cases of successfully performed procedures with no reported iatrogenic BDI or significant complications [3], indicating the safety of the procedure despite its challenging aspect. A detailed analysis of the 93 reported cases revealed that the most commonly utilized technique was the 4-port “American Mirror Technique” (Fig. 9), with the surgeon and his assistant positioned on the patient's right side and the monitor on the left. Most surgeons were right-handed, and the median reported operative time was 74 min (range: 30–240 min), and only one case of acute cholecystitis required conversion to open due to difficulty in identifying the cystic duct. In another recent literature review by Alkhlaiwy et al., chronic cholecystitis was found to be the main indication for surgery in the majority of SIT cases, with acute cholecystitis reported in only 11 out of the 92 cases [21]. The reported cases in the literature highlight the extra caution and attention given to preparation and planning in both elective and emergency settings. However, this was not the case with our patient, who was immediately rushed from the emergency room to the operating room after the diagnosis of acute cholecystitis.

To avoid BDI, it is essential to adhere to the basic principles of safe laparoscopic cholecystectomy, including the identification of the Critical View of Safety (CVS) (which was not identified in our case), the selective use of intraoperative cholangiogram, and the low threshold of conversion to open surgery in cases of poor progression during the procedure [3,21]. Some reports have suggested referring such patients to left-handed surgeons or a tertiary referral to an experienced HPB center if available to limit complications [21,22].

The management of BDI depends on the timing, type, and extent of the BDI. Various approaches can be employed, including endoscopic, surgical, and radiological [14]. Surgeons are advised to begin by utilizing all available radiological modalities, including ultrasound, CT, MRI, ERCP, and MRCP (the gold standard in BDI classification [14,23]), to identify the type of BDI and plan the appropriate management [24]. If imaging reveals a bile leak or fluid collection, immediate placement of a drain under radiological guidance is recommended [14].

Our management began with a careful review of the videos from the original laparoscopic cholecystectomy surgery and suspected CBD injury. We implemented a standard stepwise approach for CBD injury after laparoscopic cholecystectomy in terms of workup, diagnosis, and management. Given the complexity of the situation, we utilized all available imaging modalities, including CT scans, MRCP, ERCP, and PTC, to accurately identify the type of injury and facilitate the management of this complication. Due to the complexity of the case and multiple associated co-morbidities, a delayed approach was chosen for this patient. Ultimately, the CBD injury was successfully managed with a standard Roux-en-Y hepaticojejunostomy [25].

This case report is the second reported case of complete CBD injury after laparoscopic cholecystectomy in a patient with SIT, despite the challenging nature of this procedure. Perhaps the very low reported rate of BDI is due to the extra care and attention the surgeons provide in this scenario or the tendency to underreport complications and mishaps in general [4].