Usefulness of an intraoperative flipped monitor in laparoscopic surgery with situs inversus totalis: a case report of laparoscopic-assisted ileocecal resection

Abstract

Background: Situs inversus totalis (SIT) is a rare congenital condition that involves complete transposition (right to left reversal) of the visceral organs. Laparoscopic surgery can be challenging because of the mirror-image anatomy. We describe a surgical innovation in laparoscopic surgery for SIT.

Case presentation: A 41-year-old man with SIT was diagnosed with an appendiceal tumor and underwent laparoscopic-assisted ileocecal resection. Preoperatively, we evaluated anatomical variations using 3D-computed tomography and simulated mirror images by watching flipped videos of patients with normal anatomy undergoing similar operations. During the operation, port placement and the surgeons' standing positions were reversed. Additionally, two monitors were placed at the patient's head, with one monitor showing original images, and the other showing flipped images that looked the same as the normal anatomy. We checked the range of the mobilized region and important anatomical structures by watching the flipped monitor as needed. The patient's postoperative course was uneventful.

Conclusions: Due to the complexities of laparoscopic surgery for SIT, preoperative preparation and surgical innovation are necessary for safe surgery. Several suggestions have been made to understand anatomical anomalies and improve operability; however, surgeons must focus on the mirror-image anatomy throughout the operation. Therefore, the use of intraoperative flipped monitor will be helpful for surgeons in reducing the risk of anatomical misidentification.

Keywords: Intraoperative flipped monitor; Laparoscopic surgery; Situs inversus totalis.

Fig. 1

Preoperative examinations. a Colonoscopy showing a bulge at the appendiceal orifice. b Abdominal contrast-enhanced computed tomography (CT) showing complete “mirror-images” of the visceral organs; situs inversus totalis. c CT also showing appendiceal wall thickening, a cystic tumor with contrast effect (arrow), and an enlarged lymph node close to the tumor (arrowhead). d 3D-CT showing no vascular anomalies, except for completely inverted vessels. The arrow heads indicate the ileocolic artery

Fig. 2

Location of surgeons, trocars, and monitors. The surgeons’ standing positions and trocar placements were reversed from normal. Two monitors were placed at the patient’s head. One monitor showing original images, while the other showing flipped images that looked the same as the normal anatomy. The images displayed on the monitors were exchanged according to the surgical situation

Fig. 3

The situation of the surgery. The range of the mobilized region and important anatomical structures were checked by watching the flipped monitor, and the subtle confusion and misrecognition regarding the unfamiliar anatomy was corrected as needed

Fig. 4

Operative findings with horizontally flipped images. a The mesentery of the ileocecum was dissected from the retroperitoneal tissue, paying close attention to the gonadal vessels. b The transverse portion of the duodenum was identified, and dissection was performed along the descending portion of the duodenum. c The hepatic flexure was mobilized. d Additional dissection around the duodenum and pancreatic head was performed

Fig. 5

The setting screen of an intraoperative flipped monitor. To turn on the monitor, the mirror button on the image effect page must be pressed