A 55-year-old female patient presented to surgical out-patient department (OPD) with chief complaints of pain and left hypochondrium for the last 3 days accompanied by nausea and vomiting. She presented a big dilemma to the attending surgeon as all the clinical signs and symptoms pointed towards symptomatic cholelithiasis, but the pain in the left hypochondrium totally contradicted the diagnosis. It was only with the help of radiological investigation reports that we were able to confirm it as a case of situs inversus totalis. Her chest X-ray typically depicted dextrocardia and spiral computed tomography (CT) scan showed transposition of all major abdominal organs. Echocardiography was carried out and revealed normal cardiac parameters with an ejection fraction of 60%.\nPre-anaesthetic evaluation revealed Mallampatti class II patient with a slight retrognathia, a pulse rate of 74/min, blood pressure of 130/78 mmHg and normal profile of laboratory investigations. She had a history of intermittent respiratory tract infections, especially during the winter season. At present, the patient had no systemic complaint pertaining to any organ system except for the gall bladder disease. A decision to operate the patient was taken and she was posted for open cholecystectomy.\nTablet ranitidine 150 mg and tablet alprazolam 0.25 mg were administered as premedication a night before and 1 h prior to the surgical procedure with a sip of water. In the operation theatre, a good intravenous (IV) access was secured with a wide bore cannula. Induction of anaesthesia was achieved with O2, isoflurane, propofol 120 mg, butorphanol 1 mg and succinylcholine 100 mg. During induction, we encountered masseter spasm immediately after the administration of succinylcholine, which lasted for approximately 45 s, and disappeared spontaneously, but we were able to ventilate the patient with bag and mask during this episode. Intubation was extremely difficult as the larynx was placed quite anteriorly and the laryngoscopic view could be best labelled as Cormack Lehane grade-III. Maintenance of anaesthesia was carried out with injection vecuronium and low concentration of isoflurane in oxygen and nitrous oxide mixture. The peri-operative period was characterized by frequent copious secretions from the respiratory tract that had to be cleared regularly for smooth ventilation. Inj. Hydrocortisone 100 mg was given prophylactically to prevent any bronchospasm. The surgical procedure was smooth and uneventful, and lasted for about 1 h. At the end of surgery, inj. Neostigmine and glycopyrrolate were administered but extubation was delayed as the patient developed prolonged post-operative apnoea. Therefore, extubation was performed only after establishing the return of all protective airway reflexes and establishment of regular breathing pattern. Infiltration of surgical incision site was carried out with 8 ml 0.375% of ropivacaine. The recovery period and hospital stay were uneventful and the patient was discharged in a satisfactory condition on the eighth post-operative day and was called for follow-up after 2 weeks.
A 39-year-old woman who had previously undergone an open gastric banding procedure 20 months earlier for morbid obesity presented with increased weight gain. Preoperatively, her weight had been 108 kg. Her weight at presentation was 106 kg (body mass index 42 kg/m2), a percentage excess weight loss (EWL) of only 1.9%. Her medical history was significant for hypertension, noninsulin-dependent diabetes mellitus, hypothyroidism, obstructive sleep apnea, and situs inversus totalis. The presence of situs inversus was initially discovered during her first weight loss operation and confirmed by computed tomography of the abdomen []. The operating surgeon began the case laparoscopically, but upon recognizing the altered anatomy made the decision to convert to an open gastric band placement. Given the failure of this first procedure to produce meaningful weight loss, the patient was scheduled for laparoscopic removal of the gastric band with concurrent SG.\nThe patient was positioned supine on the operating room table. Secondary to the presence of situs inversus, the Veress needle was placed in the right upper quadrant to avoid the liver. A 12-mm trocar was placed five fingerbreadths above the umbilicus, just to the right of midline. Next, a 5-mm trocar was placed in the left lower quadrant approximately two fingerbreadths below the umbilicus in the midclavicular line. A 12-mm port was then placed under direct vision in the left midclavicular line approximately five fingerbreadths above the umbilicus. A 12-mm port was placed in the right upper quadrant in the midclavicular line, and a 5-mm port was placed in the right upper quadrant one fingerbreadth below the costal margin in the midaxillary line []. Exploration revealed extensive adhesions as a result of her previous open procedures. At this point, the stomach was identified and noted to be severely adhered to the liver, which was, in turn, adherent to the abdominal wall. The stomach was mobilized, the band was identified, and the band buckle was cut and removed. The previous fundoplication was taken down using a 3.5-mm depth 45-mm length stapler, and the greater curvature and short gastric vessels were divided using a harmonic scalpel. After performing the dissection all the way to the angle of His and exposing the left crux of the diaphragm, a 34-French bougie was placed into the stomach with the tip of the bougie sitting in the proximal duodenum. The formation of the gastric sleeve with a 4.8-mm depth 45-mm length stapler was started from a point 5 cm proximal to the pylorus muscle and directed toward the angle of His []. Eight total firings were used, thus dividing the stomach completely and forming a gastric tube over the 34-French bougie. At the most proximal aspect of the stomach, several dense adhesions to the diaphragm were encountered and eventually taken down. Following the formation of the gastric tube, the staple line was oversewn with 2-0 absorbable suture using an Endo Stitch (Covidien Inc., Norwalk, CT) device in a running fashion. An upper endoscopy was then performed to ensure there was no stricture or leak. After submerging the gastric tube underwater, air was pumped into the scope, and subsequently no leak was appreciated. Before removal of the last trocar, the detached stomach was placed into a specimen retrieval bag and removed from the peritoneal cavity via the 12-mm port in the right upper quadrant. The same trocar site was slightly extended to allow for removal of the port and band. Finally, a Jackson–Pratt drain was placed by the sleeve for surveillance purposes.\nThe postoperative course was complicated by a leak resulting in a 3.9 × 2.8 cm collection in the gastrosplenic ligament adjacent to the surgical suture line []. A Jackson–Pratt drain was left alongside the SG at the time of surgery as this is the surgeons protocol for revisional surgery. The Jackson–Pratt completely drained the collection. The patient underwent an upper endoscopy and placement of a 12-cm removable polyflex stent (Boston Scientific Inc., Natick, MA) for management of the leak []. Over the next few weeks her symptoms, mainly epigastric pain, persisted despite successful placement of the stent. Further imaging demonstrated interval migration of the stent into the stomach with no change in the size or location of the perigastric collection []. The patient was managed conservatively despite the stent movement and had eventual resolution of her symptoms. The stent was subsequently removed without any complications. Currently, the patient is 2 years out from the laparoscopic SG. She has lost approximately 60% EWL of her preoperative weight with no further complications.