Background <p>Gallstone ileus is an uncommon complication of cholelithiasis leading to mechanical small bowel obstruction that typically affects geriatric populations with significant baseline medical conditions. The optimal management approach is highly debated, specifically when choosing between simple emergency enterolithotomy alone or a complex one-stage definitive biliary procedure in high-risk patients. </p> Case presentation <p>A 79-year-old male with an ECOG performance status of 2, ASA Class IV risk classification, and known severe ischemic heart disease presented with acute mechanical small bowel obstruction. Preoperative contrast-enhanced computed tomography (CT) and subsequent emergency laparoscopic exploration identified an oversized, calcified intraluminal gallstone measuring 7 × 4&#xa0;cm impacted within the terminal ileum. A laparoscopic enterolithotomy was successfully performed without a concomitant biliary intervention. The immediate postoperative course was complicated by an acute non-ST-elevation myocardial infarction (NSTEMI) detected via postoperative ECG. Following successful stabilization, the patient recovered gastrointestinal function and was safely discharged home after one week with structured outpatient cardiology follow-up.</p> Conclusions <p>This case shows that an isolated laparoscopic enterolithotomy can serve as a technically feasible option for large gallstone ileus in selected high-risk patients when executed by experienced hands. However, clinicians must maintain extensive vigilance regarding perioperative cardiovascular strain, as the surgical resolution of obstruction must be balanced against severe potential cardiac complications.</p>