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

Background

Situs inversus totalis (SIT) is a rare congenital anomaly with an incidence of approximately 1 in 8000–25 000 births, in which the internal organs are positioned in a mirror image of their normal positions [1]. Due to its rare incidence and the mirror-image transposition of organs, laparoscopic surgery for an SIT patient is considered to be more difficult [2] and requires a modification of the standard procedure. Several studies for laparoscopic colectomy in patients with SIT have been published recently [3–8], wherein surgical techniques and preoperative preparation have been reported.

In the present case report, we present a unique case of a laparoscopic colectomy for transverse colon cancer with intracorporeal anastomosis in a patient with SIT, and discuss the usefulness of preoperative image training.

Case Report

A 63-year-old woman with congenital SIT was admitted to our hospital with a diagnosis of transverse colon cancer. Colonoscopy revealed a type-0Is polyp in the transverse colon, and a VI pit pattern was observed by magnifying chromoendoscopy (Figure 1A). Computed tomography (CT) revealed SIT and a mass in the transverse colon close to the hepatic flexure (Figure 1B), but no lymph node metastasis or distant metastases. Since carcinoma with mild submucosal invasion was suspected and the patient herself was reluctant to undergo an operation, endoscopic submucosal dissection (ESD) was performed. Histological examination of the resected specimen revealed massive submucosal invasion (≥1000 µm) and lymphovascular infiltration. Following the ESD, the patient was referred to our department for further surgical intervention.

The patient was 157 cm tall and weighed 75 kg (with a body mass index of 30.4 kg/m2). The patient had undergone an appendectomy at the age of 43 years. Based on the eighth edition of the Union for International Cancer Control-Tumor Node Metastases (UICC-TNM) classification [9], the preoperative clinical diagnosis was early transverse colon cancer, T1N0M0, stage I. We scheduled a partial laparoscopic colectomy with dissection of the D2 lymph nodes and intracorporeal anastomosis.

Three-dimensional CT angiography was used to observe the anatomy and variation in the mesenteric vessels, and this clearly displayed the anatomy of the vascular arch (Figure 1C). The main feeder of the primary tumor was the middle colic artery (MCA).

To ensure successful laparoscopic surgery, we repeatedly reviewed a horizontally flipped video of a normal laparoscopic colectomy and shared preoperative images of coordinated movement by the operator and first assistant.

After the induction of general anesthesia, the patient was placed in the supine position with her legs spread. The monitor was placed on the left side of the patient. The right-handed surgeon and camera operator were positioned on the right side of the patient, while the first assistant surgeon was on the left side. Pneumoperitoneum was established to a pressure of 10 mmHg using the transumbilical technique, and 5 trocars were placed as shown in Figure 2. As expected, laparoscopic exploration showed complete transposition of the abdominal viscera (Figure 3A). Preoperative endoscopic tattooing (Figure 3B) was used to determine the tumor location.

First, mobilization began at the terminal ileum and proceeded to the hepatic flexure in a medial-to-lateral approach (Figure 3C). The pancreatic head was exposed, and the transverse colon was divided. The omentum was separated from the trans-verse mesocolon. Once the left-sided colon was completely mobilized, the mesentery was incised at the root of the MCA and its branches were confirmed (Figure 4A). Both branches of the MCA and veins that run parallel to the arteries were li-gated and transected. A D2 lymph node dissection was performed. After resecting the colon on both sides of the lesion using blue-load linear endoscopic staples (ECHELON FLEX™ ENDOPATHR® Stapler; Ethicon, Tokyo, Japan) (Figure 4B), the proximal and distal colon were laid in an overlapping fashion. Side-to-side intracorporeal anastomosis was performed using blue-load linear endoscopic staples (Figure 4C), and the common-entry incision was closed by hand-sewn running suture using barbed polydioxanone sutures (PDS) (Spiral PDS PLUS® STRATAFIX®; Ethicon, Tokyo, Japan) (Figure 4D). The mesenteric defects were closed using non-absorbable sutures.

The intraoperative findings were similar to those observed in the preoperative images, and this enabled the surgery to be performed with greater confidence (Figure 5).

The specimen was extracted through a skin incision, approximately 3.5 cm, extending to the umbilical port site. The operation time was 257 min with minimal blood loss.

The patient commenced with a solid diet on the third postoperative day, and was discharged on the eighth postoperative day without any complications.

Discussion

Herein, we present the case of a patient with transverse colon cancer and SIT who underwent partial laparoscopic colectomy with intracorporeal anastomosis. Besides understanding the blood vessel variation using 3-dimensional CT angiography, image training using a horizontally flipped video of a standard laparoscopic colectomy was very effective as a means of pre-operative assessment.

Although SIT is often associated with various congenital anomalies, including congenital heart defects, renal dysplasia, and biliary atresia [1], there is no definite relationship between SIT and malignant tumors [10].

Several studies have recently reported the ingenuity of laparoscopic colectomy in patients with SIT to overcome technical difficulties due to the mirror-image anatomy. In addition to changing the operator position [3] and trocar placement [6], many reports suggest 3-dimensional CT angiography [3,5,7,8]. SIT is often associated with abnormal angiogenesis of blood vessels [11]. Therefore, it is essential to understand the patient’s anatomy and the applicable laparoscopic procedures. In our case, we used flipped movie editing for preoperative assessment.

Flipped movie editing is a standard feature of many video editing software packages, and it is a simple and useful tool; this allowed those involved in the procedure to view images that were similar to the actual field of view before surgery.

It should be noted that the forceps and devices are moved in opposite directions to that in the horizontally flipped video during the actual surgery. The patient’s cancer was close to the hepatic flexure, which meant that mobilization from the cecum to the transverse colon was required. During the actual surgery, the confusion created by mirror-imaging was able to be avoided by positioning the operator and assistant similarly to the medial-to-lateral approach used for normal left-sided colon cancer. Because of the magnified laparoscopic view, vascular ligation and lymph node dissection were performed without confusion. Horizontally flipped video is very useful for understanding images associated with such surgical developments.

Because of the SIT, the dominant forceps were oriented differently from normal forceps. Several reports have described a potential disadvantage for right-handed operators during laparoscopic cholecystectomy [12–14]. However, 2-handed operation itself is a common and essential technique in most laparoscopic surgeries. Furthermore, Karabay et al have reported that experience in advanced laparoscopic surgery may be considered as an important factor to decrease technical problems associated with SIT [15], and that the limited mobility of forceps could be overcome through coordinated movements of the operators and the assistant. Therefore, we believe that the most important factor in operating on patients with SIT is careful preoperative assessment rather than hand dominance.

Conclusions

With careful preoperative assessment that takes into account the mirror-image anatomy and the planned laparoscopic procedure, patients with SIT should be able to fully benefit from minimally invasive surgery. A horizontally flipped video of a normal laparoscopic colectomy was useful in the present case, and indeed can be deemed essential for achieving a successful operation in patients with SIT.