SIT is a rare congenital anomaly, with an incidence of approximately 1 in 10000–20000 individuals.^1,2) The occurrence of choledocholithiasis itself is not uncommon after gastrectomy. However, patients who undergo R-Y reconstruction present unique diagnostic and therapeutic challenges because ERCP is technically difficult or often impossible to perform.^11–13) In our case, ERCP was unsuccessful because the endoscope could not reach the papilla, given the long Roux limb and dense postoperative adhesions. Although reported as a possible alternative, balloon-assisted ERCP was considered impractical in this situation because of the extensive adhesions and complex anatomy. Therefore, surgical intervention remains the mainstay of treatment in such cases, particularly in moderate acute cholangitis, as defined by the Tokyo Guidelines 2018, in which timely biliary decompression and definitive stone removal are required. The combination of SIT, a history of total gastrectomy with R-Y reconstruction, and LCBDE makes the current case remarkably rare and clinically significant.

From a diagnostic perspective, situs inversus can delay the identification of biliary disease because of atypical symptom localization.^2,3) Patients frequently exhibit left-sided upper abdominal pain rather than the typical right-sided pain seen in orthotopic anatomy. In our case, recurrent cholangitis was ultimately confirmed via imaging, which showed choledocholithiasis in the mirror-image anatomy.

Technical challenges are another important consideration. In patients with situs inversus, port placement and surgeon positioning must be individualized based on the mirror-image anatomy. However, a strict mirror-image configuration is not always optimal. Rather than simply mirroring the anatomy, the surgeon’s dominant hand and ergonomic factors should also be considered in port placement. Previous reports of SIT cholecystectomy have emphasized similar adjustments.^3,4) In our case, the surgery was performed via left-sided ports due to dense adhesions, further emphasizing the need for individualized strategies beyond mirror-image placement.^3–5) Furthermore, because of dense adhesions around the midline, the surgery was completed using left-sided ports only, thereby confining all operative maneuvers strictly to the left half of the abdominal cavity, a strategy that allowed safe access despite the altered anatomy.

In addition, based on the operative experience, several technical tips should be highlighted. First, placement of traction sutures on the CBD provided effective exposure and facilitated choledochotomy, a maneuver also described in previous reports.^8,9) Second, impacted stones were fragmented within the duct, size-reduced to improve mobility, and then retrieved with basket forceps. This underscores the importance of preparing multiple retrieval devices.¹⁰⁾ Third, primary closure with a barbed suture enabled secure, efficient repair without requiring T-tube drainage, aligning with contemporary evidence favoring PDC^14,15) and reports supporting barbed suture use for choledochotomy closure.^21–23)

Comparison with the existing literature reveals both similarities and differences. Some reports have shown that laparoscopic cholecystectomy is feasible in patients with situs inversus, confirming its safety when performed by experienced professionals.^1–7) The number of studies on LCBDE in situs inversus is significantly limited,^8–10) though newer case reports have been published.^14,15) In general, after total gastrectomy with R-Y reconstruction, retrograde endoscopic access to the CBD is technically challenging.^11–13) The current case is unique as it shows the coexistence of complete situs inversus and prior total gastrectomy with R-Y reconstruction, as well as the successful completion of LCBDE using a left-sided port strategy under dense adhesions. Importantly, the fact that the procedure could be completed laparoscopically provided the additional benefit of accomplishing definitive treatment in a minimally invasive manner, thereby underscoring the value of laparoscopic management as an alternative to open surgery.²⁴⁾

The novelty of this report lies in three major aspects. First, the coexistence of SIT and prior total gastrectomy with R-Y reconstruction is exceptionally rare, presenting a unique combination of reversed anatomy and surgically altered biliary access. Second, the procedure was successfully completed using an entirely left-sided port approach, which differs from the commonly reported mirror-image configuration and flexibly adapts to severe adhesions. Third, the technical combination of intraductal stone fragmentation and primary closure with a barbed suture safely and effectively managed the ducts without utilizing C- or T-tube drainage. Together, these features highlight an individualized, minimally invasive strategy that expands the technical options for complex biliary surgery in patients with altered anatomy.

Finally, the postoperative course in our case was uneventful, which is consistent with previous reports showing that situs inversus itself does not increase the risk of postoperative complications.^1,2) Rather, the success of such procedures is significantly dependent on cautious preoperative planning, adaptation of surgical strategies, and the use of meticulous intraoperative techniques.

This case shows that LCBDE is feasible and safe in patients with SIT, even in the complex setting of previous total gastrectomy with R-Y reconstruction, provided that appropriate technical modifications are applied.