Situs inversus totalis (SIT) is a rare congenital anomaly characterised by mirror-image transposition of the abdominal and thoracic organs. We performed a percutaneous endoscopic gastrostomy (PEG) in a 49-year-old male patient with SIT and amyotrophic lateral sclerosis. To avoid injury to the left-sided liver, we made the puncture from the right side and positioned the surgeon accordingly. Both the finger sign and illuminated sign were clearly identified. Subsequently, the gastrostomy tube was placed on the anterior wall of the stomach. No complications were observed during or after the procedure. We believe that PEG insertion in patients with SIT can be performed safely by confirming specular positioning with endoscopic and radiographic images.
