Laparoscopic Colectomy for a Patient with Situs Inversus Totalis: The Usefulness of Preoperative Assessment

Abstract

BACKGROUND Situs inversus totalis (SIT) is a rare congenital anomaly in which the patient's internal organs are positioned in a mirror image of their normal locations. Laparoscopic surgery for a patient with SIT requires modification of the standard procedure. Several studies have recently reported surgical techniques for laparoscopic colectomy in patients with SIT. Herein, we present the case of a patient with congenital SIT who underwent laparoscopic colectomy for transverse colon cancer with intracorporeal anastomosis and discuss the usefulness of preoperative assessment. CASE REPORT A 63-year-old woman with SIT was referred to our department for surgical intervention following endoscopic submucosal dissection of transverse colon cancer. We performed a successful laparoscopic colectomy with intracorporeal anastomosis. Our team had no prior experience performing laparoscopic surgery on a patient with SIT; however, preoperative image training using a horizontally flipped video of a normal laparoscopic colectomy enabled the operation to be performed safely. Preoperative image training is very useful for gaining an understanding of images similar to the actual field of view before surgery. The patient was discharged without complications on the eighth postoperative day. CONCLUSIONS Careful preoperative assessment that takes into consideration the mirror-image anatomy and the contemplated laparoscopic procedure should allow patients with SIT to fully benefit from minimally invasive surgery.

Figure 1.

Preoperative images. (A) Colonoscopy showing a type 0-Is tumor on the transverse colon. (B) Computed tomography (CT) showing complete transposition of the abdominal viscera and a mass in the transverse colon close to the hepatic flexure (white arrows). (C) CT angiography showing variation in the mesenteric vessels. White arrow heads indicate the middle colic artery. A – anterior; I – inferior; R – right; S – superior.

Figure 2.

Location of surgeons and trocar placement in the patient with situs inversus totalis. O – operator; A – first assistant; C – camera operator.

Figure 3.

Intraoperative findings 1. (A) Laparoscopic view of the abdomen showing complete transposition of abdominal viscera. (B) Lesion in the proximal transverse colon (endoscopic tattoo mark) (white arrows). (C) Detachment of colonic retroperitoneal attachments at the terminal ileum level.

Figure 4.

Intraoperative findings 2. (A) Exposure of each blood vessel during operation. (B) Intracorporeal transection of the distal transverse colon. (C) Side-to-side anastomosis in an overlap fashion. (D) Closure of the common-entry incision.

Figure 5.

Operative appearance was similar to preoperative image training. White arrow shows the surgeon’s right hand, and white arrow heads show the first assistant’s right hand.