Perioperative challenges associated with a pancreaticoduodenectomy and distal pancreatectomy for pancreatic cancer in patients with situs inversus totalis: Report of two cases

Situs inversus totalis is a rare anatomic variant of a complete mirror-image transposition of the thoracic and abdominal viscera. The performance of a pancreaticoduodenectomy and distal pancreatectomy in patients with situs inversus totalis is both rare and challenging. We herein present two cases of pancreatic cancer with situs inversus totalis. The abdominal anatomy was preoperatively assessed by multidetectorrow computed tomography, three-dimensional reconstruction, and angiography. We herein report that a pancreaticoduodenectomy and distal pancreatectomy with standard regional lymphadenectomy are feasible in patients with situs inversus totalis. Due to the transposition of the viscera and major blood vessels in such cases, preoperative knowledge of the exact anatomy, mapping of anomalies, and meticulous forward planning are essential for performing these technically difficult and complex hepatobiliary-pancreatic surgeries.     

Laparoscopic Sleeve Gastrectomy for a Super-Super-Obese Patient with Situs Inversus Totalis

Situs inversus totalis is a rare defect which can present difficulties in the management in laparoscopic surgery due to the mirror-image anatomy. Herein, we report a patient with situs inversus totalis and super-super-obesity (BMI 76 kg/m²). We performed successful laparoscopic sleeve gastrectomy. Technical details of this operation, with situs inversus totalis, are presented. There were no major difficulties compared to patients with usual anatomy. There are potential diseases associated with situs inversus and obesity; therefore, a careful investigation, including a chest x-ray and cardiac and abdominal ultrasounds should be performed before surgery. Sleeve gastrectomy is an adequate procedure in super-super-obese patients with situs inversus totalis.     

Laparoscopic hemicolectomy in a patient with situs inversus totalis after open distal gastrectomy

Situs inversus totalis(SIT) is a rare anomaly in which the abdominal and thoracic cavity structures are opposite their usual positions.Occasionally,a few patients with a combination of this condition and malignant tumors have been encountered.Recently,several laparoscopic operations have been reported in patients with SIT.We report a case of an 83-year-old man with situs inversus totalis who developed colon cancer after open distal gastrectomy.Laparoscopic hemicolectomy with radical lymphadenectomy in such a patient was successfully performed by careful consideration of the mirror-image anatomy.Techniques themselves was not different from those in ordinary cases.Thus,curative laparoscopic surgery for colon cancer in the presence of situs inversus totalis is feasible and safe.     

Laparoscopic cholecystectomy in a patient with situs inversus totalis and previous abdominal surgery

Situs inversus totalis is a rare congenital defect that can present difficulties during laparoscopic surgery due to the mirror-image anatomy. We report a patient with symptomatic cholelithiasis and previous abdominal surgery in whom a chest X-ray revealed a right-sided heart, whereas abdominal ultrasound revealed that his gallbladder was located in the left hypochondrium. At surgery, the surgeon and the camera assistant were standing on the right-hand side of the patient, and the first assistant was standing on the left. The camera was introduced through an umbilical incision, and laparoscopy confirmed the situs inversus. The other 10-mm trocar was placed in the midline left of the falciform ligament and two 5-mm trocars were placed in the left subcostal midclavicular line and anterior axillary line, respectively. After dissection of multiple adhesions caused by previous abdominal surgery, a standard laparoscopic cholecystectomy was performed successfully. This report suggests that situs inversus is not a contraindication for laparoscopic surgery. However, the procedure is more difficult and potentially hazardous due to the mirror-image anatomy (particularly the transposition of biliary ducts) causing difficulties in orientation, so that extreme care is required to avoid iatrogenic injuries. Despite these factors, laparoscopic cholecystectomy can be performed safely in patients with situs inversus totalis.     

Three-trocar laparoscopic cholecystectomy in patient with situs viscerum inversus totalis: case report and review of the literature

Situs viscerum inversus totalis is a rare defect with a genetic predisposition, which can present difficulties in the management of abdominal pathology, especially in laparoscopic surgery (mirror-image anatomy). We report the case of a 52-year-old female with situs viscerum inversus totalis, known from pediatric age, with a medical history of colic pain in the epigastrium radiating to the right abdominal quadrant. Laparoscopic cholecistectomy was safely performed with a three trocar technique. To the best of our knowledge this is the first time that laparoscopic cholecistectomy by three trocars was performed in a patient with situs viscerum inversus. We also review the relevant literature concerning this issue.     

Right bronchial intubation using a left-sided double-lumen tube in a patient with situs inversus

A 74-year-old man was scheduled for resection of a pulmonary tumor in the left upper lobe. He had asymptomatic complete situs inversus, and therefore his left lung had three lobes whereas his right lung had two. Since the tumor had been growing through the left upper bronchus into the left main bronchus, it seemed that the use of a bronchial blocker in the left bronchus should be avoided. A 37-Fr left-sided double-lumen tube was rotated in the opposite direction (clockwise) and advanced easily into the right (anatomically left) main bronchus under fiberoptic guidance. One lung ventilation during the operation was performed successfully and there was no postoperative airway complication. Several ways of achieving one lung ventilation in patients with situs inversus are discussed in this report. The use of a bronchial blocker should be considered first-choice, but sometimes its use is inappropriate as in this case. Commercially available double-lumen tubes are not intended for use in cases of situs inversus. If a double-lumen tube is desired, intentional right bronchial insertion of a left-sided double-lumen tube seems to be an easy and reliable option.     

Management of a patient with situs inversus totalis with acute cholecystitis and common bile duct stones: A case report

INTRODUCTION

The incidence of situs inversus thought to be in the range of 1:10,000–1:20,000 according to Mayo et al.

PRESENTATION OF CASE

A forty-five year-old lady presented with pain in the left hypochondrium and was diagnosed to have acute cholecystitis with choledocholithiasis in situs inversus totalis. Patient underwent endoscopic sphincterotomy and common bile duct stone extraction in view of choledocholithiasis and after common bile duct cannulation patient taken up for elective laparoscopic cholecystectomy (LC) within 24 h.

DISCUSSION

The most challenging factor for performing surgery in a patient with situs inversus is dealing with the mirror image anatomy. The first laparoscopic cholecystectomy in situs inversus was reported by Campos et al. in 1991. Since then, 50 other cases have been reported in literature making a point that laparoscopic procedure is not contraindicated.

CONCLUSION

Acute cholecystitis with choledocholithiasis is extremely rare and requires expert intervention from both the endoscopist and the laparoscopic surgeons because of the reverse anatomy and the fact that both are attuned to the constant practice of the procedures in normal anatomy.Keyword: Laparoscopic Cholecystectomy in Situs inversus totalis     

Hepatic Resection for Metastatic Colon Cancer in Patients with Situs Inversus Totalis Complicated by Multiple Anomalies of the Hepatobiliary System: The First Case Report

Background  Situs inversus totalis is a rare condition characterized by a mirror-image transposition of the abdominal and thoracic viscera. In order to develop safe techniques for hepatic resection, it is important to report surgical outcomes in cases complicated by situs inversus totalis and other anomalies. Case  The patient was a 64-year-old man with situs inversus totalis who had previously undergone sigmoidectomy with regional lymphadenectomy for sigmoid colon cancer at age 62. Despite postoperative adjuvant chemotherapy, tumor markers increased and multiple liver metastases were detected on abdominal ultrasonography. Enhanced computed tomography revealed not only liver metastases but also hepatobiliary anomalies associated with situs inversus totalis as follows: (1) portal vein located anterior to the common bile duct or hepatic artery, (2) proper hepatic artery arising from the superior mesenteric artery, (3) “left” (right in normal population)-sided umbilical portion of the portal vein and total ramification of intrahepatic portal branches from that point, (4) hepatic vein directly communicating to the “left” atrium. For the treatment of hepatic metastases from sigmoid colon cancer in a patient with situs inversus totalis, “left” hepatic lobectomy, partial hepatectomy, and radiofrequency ablation therapy were performed. The postoperative course was uneventful. Adjuvant chemotherapy has been continued for 2 years after the second operation and the patient is doing well without recurrence. Conclusion  Since situs inversus totalis is occasionally accompanied by multiple hepatobiliary anomalies, careful evaluation of the related anatomy using modern imaging modalities is crucial for safe hepatic resection.     

Urinary diversion following cystectomy in a patient with situs inversus totalis.

Situs inversus totalis is a rare syndrome. The association of malignancies with situs inversus totalis is rare, and only 9 cases were reported. The management of invasive bladder cancer in the presence of situs inversus totalis has not been reported previously, and herein we report the 1st case.     

Technical difficulties and its remedies in laparoscopic cholecystectomy in situs inversus totalis: A rare case report

INTRODUCTIONLaparoscopic cholecystectomy is considered to be the gold standard surgical procedure for cholelithiasis and is one of the commonest surgical procedures in the world today. However, in rare cases of previously undiagnosed situs inversus totalis (with dextrocardia), the presentation of the cholecystitis, its diagnosis and the operative procedure can pose problems. We present here one such case and discuss how the diagnosis was made and difficulties encountered during surgery and how they were coped with.PRESENTATION OF CASEA 35 year old female presented with left hypochondrium pain and dyspepsia, for 2 years. A diagnosis of cholelithiasis with situs inversus was confirmed after thorough clinical examination, abdominal and chest X-rays and ultrasonography of the abdomen. Laparoscopic cholecystectomy, which is the standard treatment, was performed with numerous modifications in the positioning of the monitor, insufflator, ports and the position of the members of the surgical team and the laparoscopic instruments. The patient had an uneventful recovery.DISCUSSIONSitus inversus totalis is itself a rare condition and when associated with cholelithiasis poses a challenge in the management of the condition. We must appreciate the necessity of setting up the operating theatre, the positioning of the ports, the surgical team and the instruments.CONCLUSIONTherefore, it becomes important for the right handed surgeons to modify their techniques and establish a proper hand eye coordination to adapt to the mirror image anatomy of the Calot's triangle in a patient of situs inversus totalis.     

Situs inversus of donor or recipient in liver transplantation

Situs inversus is a rare anatomical abnormality that is often associated with multiple, complex malformations. In the past, patients with situs inversus were considered unsuitable candidates for transplantation or organ donation because associated visceral, and especially vascular, anomalies pose special technical difficulties. Recently, several cases of successful liver transplantation in recipients with situs inversus have been published using modified surgical techniques. This report reviews the literature and describes our own experience, including two liver graft recipients with complete and incomplete situs inversus, and one patient who underwent successful transplantation using a liver from a donor with situs inversus. Received: 10 October 1997 Received after revision: 22 December 1997 Accepted: 9 January 1998     

Situs inversus totalis: giant hiatal hernia repair by laparoscopic Collis gastroplasty and Nissen fundoplication

We report the repair of a giant hiatal hernia by laparoscopic Collis gastroplasty and Nissen fundoplication in a patient with situs inversus totalis, highlighting the unique anatomic challenges in this case. The 52-year old female patient had Kartageners syndrome, a giant hiatal hernia, and a history of chronic severe gastroesophageal reflux disease with uncontrolled regurgitation. The laparoscopic procedure was accomplished with five ports placed in a mirror-image configuration, reversed from our standard positions. After visual confirmation of the complete reversal of the intraabdominal anatomy, we performed a modified Collis gastroplasty and Nissen fundoplication. Significant technical challenges were encountered intraoperatively. To the best of our knowledge, this report is the first of its kind in the literature. The use of advanced laparoscopic techniques is highly adaptable to unusual anatomy. Laparoscopic hiatal hernia surgery is feasible in patients with situs inversus.     

Non-small cell lung cancer coexisting with pulmonary aspergilloma

A 77-year-old male with a long-standing history of smoking and working in mines was referred to our department for the evaluation of an enlarging subpleural mass in the right upper lobe. Both transbron-chial and computed tomography-guided biopsies of the mass were non-diagnostic. A partial resection of the right S² mass under video-assisted thoracic surgery (VATS) confirmed the diagnosis of primary non-small cell lung cancer. VATS right upper lobectomy (ND2a) was then performed for complete resection. Histological examination revealed that the mass composed of adenocarcinoma and the dilated bronchioles contained Aspergillus, the fungal component. Here we report a rare case of non-small cell lung cancer coexisting with pulmonary aspergillosis. The morphologic coexistence pattern of the two pathologies was believed to be the colonization of saprophytic Aspergillus in the bullous air spaces, obstructed by or contained within the tumor, according to the progression of the lung cancer.     

Laparoscopic cholecystectomy in a patient with situs inversus using ultrasonically activated coagulating scissors. Report of a case and review of the literature

Situs inversus totalis is a rare defect with a genetic predisposition, which can present difficulties in the management of abdominal pathology, especially in laparoscopic surgery, due to the mirror-image anatomy. Herein, we report on a patient with situs inversus totalis and symptomatic cholelithiasis. The patient had a successful laparoscopic cholecystectomy, using ultrasonically activated coagulating scissors. Diagnostic pitfalls and technical details of the laparoscopic cholecystectomy are discussed and a review of the relevant literature is presented.     

The management of esophageal cancer with situs inversus totalis by simultaneous hand-assisted laparoscopic gastric mobilization and thoracoscopic esophagectomy

Situs inversus is a rare disorder. We present a case of esophageal cancer with situs inversus totalis, which was successfully managed by laparoscopic gastric mobilization and thoracoscopic esophagectomy. A 57-year-old man presented to our hospital with intermittent epigastric and retrosternal pains. X-ray and computed tomography demonstrated situs inversus totalis. Upper gastrointestinal endoscopy and barium swallow showed esophageal cancer of the lower thoracic esophagus. After neoadjuvant chemotherapy, he underwent surgical intervention. Under general anesthesia, laparoscopic gastric mobilization using hand-assisted laparoscopic surgery technique was performed. The locations of the port sites were all the mirror image of the regular fashion, and the right hand of the surgeon was inserted into the peritoneal cavity. Reconstruction of the digestive tract using a gastric tube via the retrosternal route was then achieved. Finally, thoracoscopic esophagectomy with the patient in the right decubitus position was successfully completed. Postoperative recovery was uneventful.     

Limited operation of lung cancer: the role of video-assisted thoracic surgery for lung cancer

Lobectomy with systemic nodal dissection is recognized as a standard operation for lung cancer. Partial resection and segmental resection are classified as limited resections for lung cancer to preserve pulmonary function. Minor complications occur more frequently with limited resection than with lobectomy. Partial resection of the lung and simple lobectomy can be performed as video-assisted thoracic surgery (VATS). Systemic hilar and mediastinal lymph node dissection is not yet standardized using VATS. On the other hand, VATS preserves chest wall muscles. The difference between standard thoracotomy and VATS is a difference of approach to the thoracic cavity. It is most important for lung cancer surgery to be performed in the thoracic cavity with the minimum burden on patients.     

Usefulness of video-assisted thoracic surgery (Two Windows Method) in the treatment of lung cancer for elderly patients

BACKGROUND: We have been performing it less invasively by making just two, small skin incisions (Two Windows Method) for lung cancer surgery. We assess the usefulness of VATS by the Two Windows Method in elderly patients. METHODS: The subjects were 32 of the 75-year-old or older patients with primary lung cancer in our department. We assessed cases in which thoracotomy was performed and the cases in which VATS by Two Windows Method was performed, and compared postoperative complications, hospital deaths, and postoperative length of stay. RESULTS: Operations by video-assisted thoracic surgery (VATS) by the Two Windows Method were completed in 20 of the 32 patients, and a conversion to thoracotomy was done in two patients (rate 9%). Ultimately, thoracotomy was performed in a total of 12 cases, including these two. In the thoracotomy patients, the most common postoperative complication was pneumonia/atelectasis (4 cases) secondary to poor sputum expectoration. There were 2 hospital deaths due to septicemia, and there was 1 due to pulmonary artery embolism. In the VATS patients, the rate of occurrence of postoperative complications was 30%, and clearly lower than the 67% among the thoracotomy patients (p<0.05). No hospital death occurred among the VATS patients. The postoperative hospital stay of the VATS patients (21 days) was shorter than that of the thoracotomy patients (31 days), (p<0.05). CONCLUSIONS: VATS by the Two Windows Method is safer than thoracotomy, and it should be considered first for lung cancer surgery in the aged.     

Robotic-assisted Roux-en-Y gastric bypass in a patient with situs inversus

We report the case of a morbidly obese patient with situs inversus who presented for robotic-assisted Roux-en-Y gastric bypass. To do the procedure, the ports were reversed and the first assistant stood on the opposite side of the table. With these minor modifications to technique, the surgery was successfully performed without confusion over the patient’s anatomy. There were no intraoperative complications. The patient’s postoperative course was uneventful and he was discharged on postoperative day 3. We believe this is the first reported robotic-assisted Roux-en-Y gastric bypass in a patient with situs inversus.     

Esophagectomy via left thoracotomy for esophageal cancer with situs inversus totalis: Report of a case

We report a case of successful esophagectomy via a left thoracotomy for esophageal cancer in a 57-year-old Japanese man with situs inversus totalis. An upper gastrointestinal endoscopy, performed to investigate the cause of dysphagia, revealed a 7-cm irregular shaped mass occupying more than half of the circumference of the middle-third of the esophagus. Computed tomography (CT) showed enlarged mediastinal lymph nodes and situs inversus totalis. Histological examination of a biopsy specimen revealed squamous cell carcinoma of the esophagus. Although esophagectomy is usually performed through a right thoracotomy because of the left position of the aortic arch, we performed successful subtotal esophagectomy with radical lymph node dissection through a left thoracotomy. During surgery, we modifi ed the standard surgical technique in a mirrorimage fashion to complete the esophagectomy safely. The patient had an uneventful postoperative course.