Left hepatectomy for hepatocellular carcinoma in situs inversus totalis

Abstract

Introduction: One of the most prevalent primary liver cancer, particularly in Eastern Asia, is hepatocellular carcinoma (HCC), which has a poor prognosis. A rare condition known as situs inversus totalis (SIT) causes the abdominal and thoracic organs to be completely inverted.

Presentation of case: A 51-year-old woman complained of a lump in the abdomen since 4 years ago, slowly enlarging to the suprapubic area, without pain. Laboratory findings showed an alpha-fetoprotein level was 13.24 IU/mL. A three-phase abdominal CT scan showed a left lobe hepatoma with local metastases and situs inversus totalis. The patient was diagnosed with left lobe HCC cT2N0M0, stage II, Barcelona Clinic Liver Cancer (BCLC) A, Child-Pugh A, Karnofsky 80 % and SIT. In this case, segment II, III, and IV left hepatectomy was performed with the crushing clamp technique. The main challenges during surgery were the inverted intra-abdominal organs, where the liver was located on the left and the spleen on the right, and the very large tumor size of approximately 28 cm × 20 cm.

Discussion: This interesting case creates challenges in clinical practice, particularly in surgery, due to the reversal of the normal anatomy. Thus, accurate imaging is crucial for diagnosis and treatment planning. The surgeon should remain adaptable while performing the procedure for mirrored anatomy in situs inversus.

Conclusion: The unique anatomy may make the liver resection procedure for HCC in patients with SIT challenging. Surgery involving these patients with inverted anatomy can be assisted by the appropriate preoperative imaging and staging using BCLC.

Keywords: Hepatectomy; Hepatocellular carcinoma; Liver surgery; Situs inversus.

Fig. 1

A) On chest X-ray examination, dextrocardia was found with situs inversus totalis and no signs of metastases. B) Multislice computerized tomography (MSCT) abdomen three-phases on arterial phase. Hyperenhancement in the arterial phase. Right hepatic artery (blue arrow). C) Multislice computerized tomography (MSCT) abdomen three-phases on venous phase. The main portal vein (red arrow) originating from a superior mesenteric vein. Aortae (green arrow). Apex cordis on the right hemithorax depiction of the situs inversus (orange arrow). D) Intraoperative findings, identification of hepatic parenchymal demarcation. E) Total left hepatectomy with crushing clamp technique. F) Gross specimen 28 × 20 cm in size. G) Histopathological examination showed nests of malignant cells with atypical nuclei and eosinophilic cytoplasm. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)