A 38-year-old male presented with left-sided hydrocele and indirect inguinal hernia of long duration. His medical history included repeated upper respiratory tract infection requiring frequent hospitalization in childhood and was diagnosed to have a ventricular septal defect (VSD) and situs inversus at the age of 7 years. On examination, the apical impulse was felt in right 5th intercostal space with right precordial bulge. A holosystolic murmur (Grade 3/6) was heard in the right 2-4th intercostal spaces with a loud P2 and normal vesicular breath sounds. The hemoglobin of 16.3 g/dl and platelets of 2,30,000/mm3 were noted on blood investigations. Chest X-ray showed dextrocardia and a right-sided “stomach bubble” []. Situs inversus of abdominal organs was seen on the ultrasound. Echocardiogram (ECHO) revealed dextrocardia, subaortic VSD, mildly dilated right ventricle and atrium, moderate tricuspid regurgitation, and pulmonary arterial hypertension (60 mmHg). ECG was consistent with mirror image dextrocardia.\nA combined spinal epidural anesthesia (CSEA) was planned for hernioplasty and hydrocelectomy. The patient was premedicated with pantoprazole and ondansetron on the morning of surgery. A 20G arterial line was secured for invasive pressure monitoring. Continuous ECG, invasive blood pressure, and pulse oximeter was instituted. With strict asepsis and the patient in sitting position, an 18-gauge epidural catheter was placed at L1-L2 interspace. Using a 25-gauge spinal needle, subarachnoid block was performed with 1.8 ml of 0.5% bupivacaine and 25 μg fentanyl at L3-L4 interspace. The patient's heart rate, blood pressure, and oxygen saturation remained stable during the intraoperative period. Fentanyl 50 μg and graded doses of 0.2% Ropivacaine was administered epidurally to achieve segmental anesthesia for the subsequent operative period. Further intraoperative course was uneventful. In the first 24 hours postoperatively, patient was monitored in the ICU. Buprenorphine 120 mcg twice daily was administered for epidural analgesia. Further postoperative period was uneventful and subsequently, the patient was discharged home.
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.