Thoracoscopic surgery in the prone position for esophageal cancer in patients with situs inversus totalis: A report of two cases

Abstract

Introduction: Situs inversus totalis (SIT) is a rare congenital condition characterized by a complete transposition of thoracic and abdominal organs. Here, we present two successful cases of left thoracoscopic esophagectomy in the prone position for SIT-associated esophageal cancer.

Presentation of case: Our first case was of an 82-year-old man who underwent a left thoracoscopic esophagectomy in the prone position, followed by hand-assisted laparoscopic gastric mobilization. Surgical duration and blood loss were 661min and 165g, respectively. His postoperative course was uneventful. The second case was of a 66-year-old man who underwent a left thoracoscopic esophagectomy in the prone position, followed by gastric mobilization via laparotomy owing to a concomitant intestinal malrotation and polysplenia. Surgical duration and blood loss were 637min and 220g, respectively. We trained for the surgical procedures preoperatively using left-inverted and right-inverted thoracoscopic surgical videos of patients with normal anatomy.

Discussion: Surgical procedures in SIT patients are challenging owing to their mirrored anatomy. Recognition of their variations is thus important to avoid intraoperative accidental injuries. Left-inverted and right-inverted thoracoscopic surgical videos of patients with normal anatomy were found to be useful for image training prior to the actual surgery.

Conclusion: Thoracoscopic surgical treatment for esophageal cancer associated with SIT in the prone position can be performed safely, similar to the manner performed for thoracoscopic surgery in the right decubitus position, or surgery via an open thoracotomy. Gastric mobilization via laparotomy should be considered in patients associated other anatomic variations.

Keywords: Intestinal malrotation; Laparoscopy; Polysplenia; Thoracoscopy; Video.

Fig. 1

(A) Chest X-ray showing dextrocardia and a right aortic arch. (B) Computed tomography images of the chest showing that the thoracic position of the organs is a mirror image of the normal position. (C) Abdominal computed tomography showing that the abdominal position of the organs is a mirror image of the normal position.

Fig. 2

(A) Thoracoscopic operative view of the patient showing that the thoracic organs are in mirror image positioning. The arrow shows the left-sided right recurrent laryngeal nerve; the arrowheads show the left-sided right vagus nerve. (B) Right-inverted and left-inverted view of a previous surgery in an anonymous patient with normal organ positioning for preoperative image training. The arrow shows the right recurrent laryngeal nerve, and the arrowhead shows the right vagus nerve.

Fig. 3

(A) Abdominal computed tomography reveals that the abdominal position of the organs is a mirror image of the normal, with presence of multiple splenic nodules on the right side of the abdominal cavity. Arrows show multiple splenic nodules. (B) Findings of a computed tomography image suggest the occurrence of intestinal malrotation. The duodenum lacks a horizontal portion (arrows). A larger part of the subsequent colon was not fixed in the retroperitoneum and was present on the right side of the abdominal cavity.