Laparoscopic Common Bile Duct Exploration for Choledocholithiasis in a Patient with Situs Inversus Totalis and Prior Total Gastrectomy with Roux-en-Y Reconstruction: A Case Report.

introductionSitus inversus totalis (SIT) is a rare congenital condition characterized by mirror-image transposition of the thoracic and abdominal viscera. Herein, we report a rare case of laparoscopic common bile duct exploration with choledochotomy and stone extraction in a patient with SIT and a history of total gastrectomy with Roux-en-Y (R-Y) reconstruction. CASE PRESENTATION: A 70-year-old woman with SIT and a history of total gastrectomy with R-Y reconstruction presented with recurrent cholangitis caused by choledocholithiasis. Conservative therapy led to temporary improvement, but symptoms recurred after 2 months. Percutaneous transhepatic gallbladder drainage was followed by laparoscopic cholecystectomy and laparoscopic common bile duct exploration (LCBDE) one week later. Dense adhesions along the midline and right upper quadrant prevented standard port placement, so all maneuvers were confined to the left abdomen. A 3-cm umbilical minilaparotomy accommodated a Lap Protector with two 5-mm working ports, and additional 5-mm ports were inserted in the left lower abdomen for the camera, in the left upper abdomen for the assistant, and above the choledochotomy site for choledochoscope access. CT confirmed complete SIT and an 18-mm common bile duct (CBD) stone with upstream dilation. Endoscopic retrograde cholangiopancreatography was impossible because the long Roux limb and adhesions limited endoscopic access. Choledochotomy was aided by traction sutures; the impacted stone was fragmented intraductally and retrieved with basket forceps. The CBD was closed primarily without drainage. The postoperative course was uneventful, and the patient was discharged on day 8. No complications occurred during the 4-week follow-up.

conclusionsThis case emphasizes the technical challenges of laparoscopic biliary surgery in patients with situs inversus and a history of R-Y reconstruction. The key points include individualized port placement, surgeon positioning, traction, and secure primary closure. LCBDE is feasible in patients with SIT and prior R-Y reconstruction if surgical strategies are individualized based on anatomical variation and surgical history.