Minimally invasive Ivor Lewis esophagectomy in a patient with situs inversus totalis through a total of five ports

Abstract

Situs inversus totalis is inverse placement of intra-thoracic and abdominal organs identical with a mirror image. Herein, we present a rare case of situs inversus totalis and gastroesophageal junction carcinoma treated with minimally invasive Ivor Lewis esophagectomy. A 73-year-old male patient presented with dysphagia and a diagnosis of adenocarcinoma was made. He underwent three-port laparoscopic gastric conduit preparation without using a liver retractor. Esophageal mobilization in the chest was completed with biportal video-assisted thoracoscopic surgery technique and a completely side-to-side stapled anastomosis. The patient is still alive without recurrence four years after surgery. Minimally invasive Ivor Lewis esophagectomy can be performed in these cases; however, a careful planning and rethinking of the anatomy for correct intraoperative orientation are needed. Similar surgical and oncological outcomes are expected in this patient population.

Keywords: Esophagectomy; minimally invasive; situs inversus totalis.

Figure 1. (a) Computed tomography section showing a mass at the gastroesophageal junction. (b) Laparoscopic port incisions; 5 mm right paramedian, 10 to 15 mm left paramedian and 10 to 12 mm left subcostal. (c) Thoracoscopic incisions; on the fifth intercostal space anterior axillary line and a second port on the eighth intercostal space posterior axillary line. (d) The gastrohepatic ligament is divided initially. (e) The greater curvature is freed while preserving the gastroepiploic artery. (f) Pleura over the esophagus is opened up to azygos vein over the pericardium, intermediate bronchus, and the carina. (g) Posterior wall anastomosis is completed for a double-barrel, completely stapled, side-to-side linear stapled intrathoracic anastomosis.