Laparoscopic sleeve gastrectomy in a patient with situs viscerum inversus totalis: is the life easy upside-down?

Abstract

Introduction Obesity is an epidemic on the rise [1]. The number of bariatric procedures has increased worldwide. Laparoscopic sleeve gastrectomy (LSG) is a valid therapeutic option, leading to a sustained weight loss with a low complication rate [2]. Situs viscerum inversus totalis (SIT) is the complete transposition of all the abdominal organs, occurring in about 1 in 10,000 people [3]. Laparoscopic approach in SIT is challenging due to the mirror image anatomy. Materials and methods We present the case of a 41-yearold man with a body mass index of 46.4 kg/m 2 (131 kg; 1.68 m) previously diagnosed with SIT who has undergone LSG.Results In this video, we show a LSG performed in a patient with SIT. There were no changes in the technique compared to the ''standard anatomy.'' The patient was placed on the operative table in anti-trendelenburg position with legs abducted. The surgeon stood between the legs while the assistant was on the right side of the patient and the scrub nurse on the opposite side. A 12-mm trocar was inserted with a direct technique in the right lateral flank. Carbon dioxide insufflation was done under vision. Other three trocars (12, 10, and 5 mm) were positioned in the left lateral flank, supraumbilical, and subxiphoid areas, respectively. Gastroepiploic dissection started at 5 cm from the pylorus up to the right crus. After the insertion of a 36-Fr boogie, an accurate stapling of the stomach was performed. The proximal side of the sleeve was reinforced with a non-absorbable suture. Titanium clips were placed leading to a complete haemostasis. The procedure lasted 45 min. The patient followed a ''fast-track'' protocol afterwards, with no changes in the perioperative workup compared to ''standard anatomy'' patients. He was discharged on day 2 postoperatively and no complication occured in the perioperative period. Conclusion SIT is a rare condition leading to a mirror image that can be challenging for a laparoscopic surgeon. LSG is feasible and safe also for morbidly obese patients with SIT, not requiring any change in the surgical technique and perioperative management, as long as the surgeon is well beyond the learning curve.

Laparoscopic Roux-en-Y gastric bypass in a patient with situs inversus totalis: Case report, technical tips and review of the literature

“…Laparoscopic Roux-en-Y gastric bypass (LRYGB) was performed in 5 patients (22.7%) [ [1] , [4] , [12] , [13] , [14] ]; Laparoscopic banded Roux-en-Y gastric bypass (LBRYGB) in one patient [ 9 ]; Robotic assisted RYGB (RRYGB) in one patient [ 11 ]; and laparoscopic adjustable gastric banding (LAGB) in 5 patients [ [2] , [5] , [6] , [7] , [8] ]. Laparoscopic sleeve gastrectomy (LSG) was performed in 7 patients [ [3] , [10] , [12] , [15] , [16] , [19] , [21] ]; modified duodenal switch (LSG + duodeno-jejunal bypass, and stomach-intestine pylorus sparing; SIPS) in two cases [ [17] , [18] ], and there was a single case of Omega loop gastric bypass or mini gastric bypass that was published with a Supplementary video [ 20 ].…”

“…A total of five patients underwent LRYGB [ [1] , [4] , [12] , [13] , [14] ], one had a banded RYGB [ 9 ], another patient had a robotic assisted surgery[ 11 ], and one patient had an Omega loop or mini gastric bypass [ 20 ]. A total of seven patients had LSG [ [3] , [10] , [12] , [15] , [16] , [19] , [21] ], one patient had a LSG with duodeno-jejunal bypass [ 17 ] and another patient had SIPS [ 18 ]. Only five patients had LAGB [ [2] , [5] , [6] , [7] , [8] ].…”

Laparoscopic Sleeve Gastrectomy in a Patient With Situs Inversus Totalis and Kartagener Syndrome

“…Port placement will be modified and most of the dissection will be from the right side of the body because of the stomach position. In contrast, Salerno et al presented a successful LSG in SI with no alteration of port placement or surgical technique [ 26 ]. Additional port placement can be utilized for additional traction or easy access as described in two cases of LSG in SI [ 19 , 20 ].…”

“…All of the cases achieved variable but significant postoperative weight loss. Data on weight loss were lacking in five cases [ 16 , 21 , 26 , 30 ].…”

Laparoscopic sleeve gastrectomy in a patient withsitus inversus totalisand Kartagener syndrome: an unusual surgical conundrum

“…A total of 25 articles with 27 cases were identified. These comprise 6 cases that underwent LGB,5 9–13 9 LRYGB5 14–21 and 12 LSG 22–32. Among these cases, only one case of Kartagener syndrome was identified for each LGB,11 LRYGB16 and LSG 26.…”