Laparoscopic Sleeve Gastrectomy and Situs Inversus Totalis: Case Report and Literature Review

Situs Inversus Totalis (SIT) is a recessive congenital autosomic anatomic anomaly in which an abdominal and/or thoracic organ is placed into a position similar to “a mirror reflection” in comparison to the normal position of the human organs seen from a sagittal plane. Fabricius was who firstly reported a SIT case in humans since them there are few cases reported. SIT is a relatively uncommon condition, it’s been said to be found approximately in 1 out of 5000 - 20000 individuals [1].

Obesity is a current highly prevalent clinical condition which is associated to several comorbidities such as diabetes mellitus, high blood pressure, ostheoarticular alterations, coronary heart disease, cerebrovascular disease, and so forth [2]. Thus, correcting obesity is a key point towards improving patient’s health. Bariatric surgery is nowadays the most effective intervention within the weight control field; plus, its outcomes are helpful when it comes to managing obesity-related diseases. In regards of bariatric surgery, the laparoscopic approach has been proved as the ideal one [3]. However, such approach have additional technical difficulties for the laparoscopic surgeon due to SIT’s. Based on the lack of worldwide reports of laparoscopically-approached weight control surgeries in SIT-presenting patients we are glad to provide a successfully performed laparoscopic gastric Sleeve procedure case.

A male 47 years old patient suffering from high blood pleasure, type 2 diabetes mellitus, obstructive sleep apnea, chronic sinusitis, osteoarthosis, morbid obesity, and situs inversus totalis who was being treated by the internal medicine, endocrinological and nutritional services and who had been prescribed orlistat, glargine insulin, glulysine, fluoxetine, mometasonefuroate nasal spray, and gemfibrozil. This patient was also being treated with continuous positive airway pressure CPAP interventions and was under various nutritional and exercise schemes. Based on the patient’s poor response to such management, it was suggested that a bariatric surgery be performed to him. This patient was received to our bariatric surgery services with the following anthropometric data: height: 1.75m; weight: 121 kg; BMI: 40.9 kg/m²; HbA1C: 8.6%. The patient was also performed routine tests and some specialized tests whose results were: echocardiogram showing a conserved biventricular function and showing the presence of situs inversus; thoracic X-rays: cardiac silhouette located towards the right side; upper digestive endoscopy: no alteration found besides the presence of situs inversus; nasosinuscopy: chronic rinosinutisis associated to nasal polyps, left septal deviation and left nasal turbinate hypertrophy. (Figure 1)

Figure 1: The apex of the heart on the patient’s right side shown in chest X-ray.

The patient was taken into the Operating Room (OR) on June 4^th, 2019. The patient was operated under general anesthesia. The operating team placed into American position was composed of the head surgeon to the right, the second-in-charge surgeon to the right, the assistant surgeon and the surgical instrumental to the left. Local anesthesic was administrated through infiltration prior to the skin incision’s being made. (Figure 2)

Figure 2:2Port Set Up.

A 15mm optical trocar was introduced into the epigastrium to the right side of the medial line. A pneumoperitoneum was created and a set 30mm lenses was introduced. Under direct vision, a 15mm optical trocar was introduced into the mesogastrium, then back to the epigastrium, but closer to the left side of the medial line this time, and finally reaching the right flank. At this point, a 5mm subxyphoideal trocar was introduced and the exploration process was performed, this allowed the confirmation of the presence of SIT. The spleen was located into the right hypocondriac region, and so were the gastric fundus and its major curve under the II and III hepatic segments, located to the right of the falciform ligament. Towards the left side, into the hypochondriac region the gallbladder was found under the IV and V hepatic segments. It was also found a great hiatal hernia which contained the gastric fundus and epiplon. The patient’s stomach was noticed to be of great size and with a major curve pointing towards the right whereas the lesser curves pointed towards the left. The hiatal hernia got reduced. Gastrocolic ligament and short gastric vessel were dissected with a 37/5mm cm Maryland Jaw Laparoscopic device. A bougie was inserted to confirm a satisfactory gastric remnant size. Then methylene blue test was done without any sign of leak. (Figure 3 and Figure 4)

Figure 3: 3D Lafragmatic hernia at the left and the liver at the right side.

Figure 4: Liver at the right position.

The patient was allowed to use his oral administration route the first postoperative day, and was given medical discharge on the second postoperative day. On the fifth postoperative day, the patient was taken back into the hospital due to upper gastrointestinal bleeding, he did not need blood transfusion either additional procedure. A month later after the procedure, the patient was seen as part of the postoperative routine appointments and his fasting glycemic levels were 110 mg/dl and his blood glucose levels after a glucose load test were 125 mg/dl. His HbA1C levels were of 6,18% without medication. His body weight was of 88 Kg and his Body Mass Index (BMI) was 29, 7kg/m².

PubMed, ResearchGate, and Google Scholar search revealed a total of 27 papers with 30 cases of bariatric surgeries performed on patients with Situs Inversus between 1998 and 2019. Using the following search terms: “obesity”, “morbid obesity”, “bariatric surgery” “obesity surgery” “situs inversus” “situs inversus totalis’. The following information was collected: first author of article; publication year; patient’s gender, BMI age and preoperative study, surgical technique and complications.

We Found 27 case reports with 30 patient who were into bariatric surgery, 18 (60%) patient were female, 8 (26.7%) were male, in 4 of them the author did not give any demographic information. The average age was 29 year, the younger patient was 19 year [4] and the older 59 year [5]. The average BMI was 44.72kg/m², BMI range was between 76 kg/m² and 35 kg/m². There were 2 patients with Kartagenere Syndrome previously diagnostic [6,7]. Pauli et al, refer this imply an additional anesthetic risk and they managed with low neumoperitoneum pressure. The second patient did not show any inconvenient.

The average operating time was 112.83 min. The French position was performed in 9 (30%) patient and the mirror position in 15 (50%) patient, in 6cases the author did not give this information.

LRYGB: laparoscopic roux-y-gastric bypass was performed in 10 patients [4,5,7,8-13], LAGB: laparoscopic adjustable gastric banding in 5 patients [6,14-17], LSG: laparoscopic sleeve gastrectomy in 9patients [12,18-25]. SILSG: single incision laparoscopic sleeve gastrectomy in 1 patient [26]. LSG+DS: laparoscopic sleeve gastrectomy duodenal switch in 1 patient [27], SIPS: stomach intestine pylorus sparing surgery in 1 patient [28], RRYGB: robotic assisted roux-Y-gastric bypass in 1 Patient [20]. LOAGB: Laparoscopic One-Anastomosis Gastric Bypass in 2 patient [3,29].

Complications were reported in 3 patients. One patient with band erosion [6] and the other one with suture line leakage [19], the authors did not related it with the anatomy changes seen in situs inversus. In the last complication the author has to converse for technical difficulties as a result of anatomical changes noticed intraoperative [13]. (Table 1)

Table 1: Bariatric surgery In situs inversus: Literature review.

Situs inversus related with obesity is a rare condition, those patient have a similar high cardiovascular risk compared to the general population. Patient with situs inversus can have bariatric surgery safely but is very important to have the routine preoperative protocol to patient with obesity (EKG, Chest X-ray, abdominal Ultrasound, gastroscopy and abdominal CT if it needed). Most surgeons reported technical aspect as the hardest part because the mirror images in situs inversus and the need to use the right hand. Finally we think bariatric surgery is an option in patient with situs inversus and obesity.

In order to performance safely this procedure in patient with situs inversus the mirror image approach has demonstrated to be effective. As Wall et al. described Robotic surgery is an option to avoid the need to change position or instrument orientation by the surgeon, which have been reported in the literature as a principal technical problem.