A 76-year-old male with a past medical history of hypertension, hypercholesterolemia, hypothyroidism, chronic obstructive pulmonary disease, diabetes mellitus type two, obstructive sleep apnea, benign prostatic hyperplasia, cerebral vascular accident with residual right-sided weakness, and dextrocardia with situs inversus presented with an abnormal nuclear stress test. Additionally, he had a family history notable for colon cancer and myocardial infarction in his mother and a thrombotic event in his father. He had no history of significant alcohol use, tobacco use, or illicit drug use, and his past surgical interventions were not cardiovascular in nature. He originally presented at an outside hospital following a syncopal event with a 45-second loss of consciousness postmicturition. At the time, he was thought to have orthostatic hypotension, and his tamsulosin was discontinued. He also underwent a nuclear stress test for the syncopal event due to additional complaints of worsening dyspnea on exertion. Nuclear stress testing demonstrated a moderate-sized reversible anterior wall myocardial perfusion defect and a moderate-sized reversible inferolateral wall myocardial perfusion defect. He was transferred to our hospital for further evaluation of symptoms and possible left heart catheterization. Cardiac catheterization revealed the already diagnosed dextrocardia along with a new diagnosis of severe ostial left anterior descending (LAD), mid-LAD, and ostial diagonal coronary artery disease. Transthoracic echocardiography (TTE) showed trace mitral valve regurgitation, mild aortic valve regurgitation, and an ejection fraction of 60%. His underlying dextrocardia with situs inversus caused diagnostic challenge with these tests as his angiographic, radiologic, and echocardiographic images were mirror images of normal cardiac anatomy. Aggressive risk factor modification was initiated, and a consult was placed to cardiothoracic surgery for evaluation for potential coronary artery bypass grafting (CABG). He underwent three-vessel CABG on day 7 of his hospitalization with alterations in management to account for his known dextrocardia with situs inversus. The electrocardiography leads and defibrillator pads were placed in reverse orientation. A left internal jugular vein central venous catheter was placed to provide direct access to the right atrium rather than standard right-sided central venous access. The arterial line was placed in the right radial artery as opposed to the institutional standard left radial artery to accommodate for the position of the surgeon during the operation. Transesophageal echocardiography (TEE) evaluation again confirmed dextrocardia (). To obtain standardly recognized TEE images, the omniplane was adjusted to 180° for the midesophageal four-chamber view. By subtracting 60°, 90°, and 120°, midesophageal midcommissural, two-chamber, and long-axis views were then obtained. Additionally, TEE confirmation of aortic and venous cannulation required turning the probe right for the right-sided aorta and left for liver visualization, respectively. Aside from these alterations in approach, induction, intubation, and anesthetic management were conducted in normal fashion and were uneventful. He remained intubated and was taken to a cardiac intensive care unit postoperatively. A thorough sign-out was given to the intensive care unit staff to ensure understanding of his anatomy and intraoperative course. He was weaned from the ventilator and extubated on postoperative day 1 and transferred to the step-down unit on postoperative day 2. His postoperative course was complicated by urinary retention and an elevation in creatinine that trended down prior to discharge. He was discharged home in stable condition with a urinary catheter in place on postoperative day 6 that was to be removed as an outpatient. Both the patient and the responsible physicians were satisfied with the successful outcome.
This is a case of a 59-year-old morbidly obese female with situs inversus totalis who presented for a laparoscopic sleeve gastrectomy. Her BMI was 38 (height 4 ft 11.5 inches, weight 188.2 pounds), and she had a lifelong history of morbid obesity and obesity-related comorbidities, including obstructive sleep apnea requiring a continuous positive airway pressure machine, an elevated hemoglobin A1c (5.8) and a fasting blood glucose increasing her risk of developing diabetes mellitus, and degenerative joint disease which significantly impacted her ability to exercise. The main challenges she identified in losing weight involved eating carbohydrate rich foods, overeating during meals and limited activity due to musculoskeletal pain. The patient had made multiple attempts to lose weight through commercial dieting programs but had been unsuccessful. The patient also completed a six-month medically supervised diet through her primary care provider, which also included working closely with a bariatric registered dietician, following a strict diet of about 1800 calories/day and performing modified exercise, about 120 minutes/week. Despite these intense medical weight loss efforts, she was unable to maintain a healthy weight. The patient was motivated to try bariatric surgery after she witnessed the significant weight loss success her daughters had from this intervention. Her greatest hope from the bariatric surgery was to be healthier and to alleviate her obesity-related comorbidities.\nThe patient’s surgical history included cesarean section and evacuation of an ectopic pregnancy. She was a former smoker, quitting over 25 years ago, and has no other history of substance or alcohol use. Family history is positive for obesity, diabetes, hypertension, coronary artery disease and hypercholesterolemia. She did not take any medications, including supplements, except for Ibuprofen 800 mg 1–3/daily for musculoskeletal pain.\nThe patient underwent a comprehensive evaluation and treatment plan prior to the surgery including: psychiatric evaluation and clearance, nutritional consultation with a registered dietician, education about bariatric surgery and pre/post op expectations, routine preoperative labs, UGI, esophagogastroduodenoscopy (EGD), pulmonary function analysis, and a cardiovascular exam. Situs inversus totalis was confirmed with abdominal X-ray and CT, and echocardiogram. Pre-procedural evaluation with UGI revealed mild gastroesophageal reflux observed to the level of the distal one-third esophagus and small sliding-type hiatal hernia. EGD revealed normal esophagus and duodenum. Stomach biopsy was obtained for antral gastritis, and no helicobacter organism was identified. Abdominal ultrasound confirmed fatty liver disease. Pulmonary function analysis including spirometry, lung volumes and diffusion was normal. A pre-procedural cardiovascular exam was performed due to dextrocardia to exclude other structural cardiac abnormalities. 2-D echocardiography with M-mode demonstrated a left ventricular ejection fraction of 60%, no structural abnormalities in the aortic, pulmonic, tricuspid and mitral valve, or right and left atrium and ventricles. Color Doppler and continuous and pulse wave Doppler demonstrated mild pulmonic regurgitation and mild tricuspid regurgitation.\nThe patient discontinued the Ibuprofen more than one month before her surgery and began a low-calorie liquid diet two weeks prior to surgery. On the day of surgery, preoperative antibiotics, Cefazolin, were given within 60 minutes before the first incision. Prior to induction, the patient received 5000 units of heparin subcutaneously and sequential compression device (SCD) boots were placed for deep vein thrombosis (DVT) prophylaxis. No beta-blockers were administered. The patient was placed in the supine position and general anesthesia was induced. A Foley catheter was placed and the patient was supported with positioning devices including: arms on padded arm boards, gel pad under left axilla, footboard with gel pads, hover mat and a bariatric safety belt over patient’s thighs. The abdomen was then prepped and draped in the standard surgical fashion.\nA Veress needle was used in the right upper quadrant to access the abdomen and insufflation was created to 15 mmHg. Veress was removed and replaced with a 5 mm trocar and the scope was placed. Additional trocars were placed in the following position: right and left 5 mm lateral trocars, right and left 12 and 15 mm supra-umbilical trocars. The placement of all retractors and graspers was adjusted accordingly to the mirror image anatomy of the intraabdominal organs. The primary surgeon was positioned on the left side of the patient and the assisting surgeon on right side of the patient. Situs inversus totalis was confirmed with the majority of the liver oriented to the patient’s right, spleen on the right, greater curvature of the stomach on the right and gallbladder on the left.\nThe operating table was placed in the reverse Trendelenburg position. The patient’s right-sided half of the liver was retracted cephalically using a Nathanson retractor to expose the vicinity of the esophageal hiatus. The peritoneum over the cardia was incised using the Ethicon Harmonic scalpel, and the plane between the cardia and the left crus of the diaphragm was opened to expose the right diaphragmatic crus. No hiatal hernia was present. A point 5 cm proximal to the pylorus along the greater curvature of the stomach was marked corresponding to the incisura angularis just proximal to the crow’s foot of Latarjet’s nerve. The vessels along the greater curvature and all the short gastric vessels were sealed and divided using the Ethicon Harmonic scalpel, freeing the greater curvature and the fundus of the stomach. A 42-French bougie was placed and oriented towards the antrum along the lesser curvature (Figure ). The stomach was stapled and divided alongside the tube in a vertical fashion towards the angle of His (Figures -).\nAn Ethicon Echelon Flex triple staple line power stapler with a total of one black, three green, and one gold staple loads was used. All staple loads were 60 millimeters in length with staple line bio-absorbable reinforcement. Hemostasis at the external staple line was achieved (Figure ). The stomach was removed from the abdomen via the left-sided 15 mm trocar (Figures , ). Intraoperative endoscopy was performed using a 5 mm Olympus Ultrathin gastroscope revealing no areas of stenosis, internal staple line bleeding, nor staple malformation or leak seen. Total operation time was 108 minutes. There were no post-operative complications.\nPost-operative care included pain management and DVT prophylaxis with SCD, heparin and early ambulation four hours post-surgery. A UGI was performed on post-op day 2 with normal findings for a post-bariatric surgery evaluation and clear fluids were started. The patient was discharged on post-op day 3 without any complications. Upon discharge, the patient had a treatment plan that was previously discussed that included instructions for diet and medications, including vitamin supplementation and antacids. At her three-month follow-up, the patient was still without complications and very pleased with her weight loss of 46.2 lbs, weighing 142 lbs (BMI 29).