238 Overcoming Surgical Challenges in Total Gastrectomy for a Patient with Situs Inversus Anomaly.

Abstract Background Gastric cancer is the fifth most common malignancy worldwide. Situs Inversus Totalis (SIT), a rare congenital condition involving mirror-image organ arrangement, poses significant challenges during abdominal surgery. Aim This case report highlights the complexities and management strategies in performing total gastrectomy for gastric cancer in a patient with Situs Inversus anomaly. Method A 65-year-old female with a Type 3 Siewert gastroesophageal junction tumor and Situs inversus anomaly received neoadjuvant FLOT chemotherapy. Restaging revealed a favorable response, and the patient underwent open total gastrectomy. Intraoperative findings included atypical vascular anatomy, hepatomegaly, bowel malrotation, and dense adhesions from prior surgeries. Surgical modifications included extensive liver mobilization and customized reconstruction with hand-sewn esophagojejunostomy and jejunojejunostomy to accommodate anatomical deviations. Results The postoperative course was largely uneventful except for a right-sided pleural effusion, managed conservatively. Histopathological analysis confirmed complete tumor resection (R0) with no lymph node metastasis (0/21), classified as pT1, pN0, pMx. The patient-initiated adjuvant chemotherapy but experienced toxicity that limited further treatment. Conclusions Gastrectomy in the context of situs inversus anomaly demands meticulous preoperative planning, adaptable intraoperative techniques, and multidisciplinary collaboration. Despite anatomical challenges, a tailored surgical approach led to a favorable oncologic outcome. This case reinforces the feasibility of complex oncologic resections in anatomically variant patients when managed by an experienced surgical team.