Duodenoscope combined with laparoscopy in treatment of biliary stones for a patient with situs inversus totalis: A case report

RATIONALE: Although endoscopic and laparoscopic techniques in situs inversus totalis (SIT) have been reported respectively, endo-laparoscopic combination therapy due to biliary lithiasis remains infrequent. We shared the experience regarding the operations with a video report and discussed the similarities and differences with the usual procedures, which proved to be challenging to some extent for SIT. PATIENT CONCERNS: Herein we present a 72-year-old man with SIT who underwent endo-laparscopic combination therapy due to choledocholithiasis and gallbladder stone. DIAGNOSIS: Choledocholithiasis; Gallbladder stone; SIT INTERVENTIONS: The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) first. He was placed in the left lateral decubitus position with basal anesthesia. As a result of the anatomical abnormality, the endoscope was rotated 180° in the 2nd portion of the duodenum. The ampulla was identified with difficulty because of a giant duodenal diverticulum nearby. After double-wire-guided cannulation, cholangiogram demonstrated filling defects and sphincterotomy was performed. This was followed by balloon ampulla dilation, sludge sweepage and nasobiliary drainage. The patient underwent standard laparoscopic cholecystectomy (LC) the next day. OUTCOMES: No complications such as bleeding, pancreatitis, perforation (after ERCP) or bile leakage (after LC) was detected. The patient was discharged after 4 days and recovered well after 3 months follow-up. LESSONS: We found that patients were not required to make changes in position; the medical staff should adapt to mirror symmetrical anatomy and operate carefully. The surgical outcomes were not affected despite the extended operation time. In addition, operators can amend usual operating habits with modified techniques for patients with SIT.