A 44-year-old man was admitted to the Ear, Nose, and Throat department of our hospital in August 2019 with chronic nasal obstruction, postnasal drip, chronic sinusitis, and chronic non-productive cough for FESS. During history-taking, the patient stated that his heart was on the right side of his chest. A chest roentgenogram and a high﻿-resolution chest and abdomen computed tomography (CT) scan identified dextrocardia (), situs inversus (), and chronic bronchitis and bronchiectasis involving both lung bases ( and ). CT sinuses showed mucosal thickening of bilateral maxillary and ethmoid and sphenoid sinuses (). KS was diagnosed based on the presence of the classical triad.\nOn admission, the patient’s vital signs, including blood pressure (systolic 112, diastolic 74 mmHg), heart rate (80 beats per minute), respiratory rate (19/min), and the peripheral capillary oxygen saturation (SpO2; 94%), were within normal range. The complete blood count and renal and liver function test results were unremarkable. The 12-lead electrocardiogram (ECG) with reversal of the limb and precordial leads showed sinus rhythm and a normal tracing. The patient had a known allergy to acetylsalicylic acid (Aspirin®) and nonsteroidal anti-inflammatory drugs, and an allergy panel was performed, which revealed positive hazelnut antibodies. Since crepitations and wheezes were heard over bilateral lung fields, the patient was prescribed oral prednisolone (50 mg, once daily (QD), oral lansoprazole (30 mg, QD), oral levofloxacin (500 mg, QD), and 0.1% xylometazoline hydrochloride nasal spray (every 8 h). Intensive chest physiotherapy and supportive care prior to surgery were provided to prevent worsening of the lung function. Additional hypertonic saline nebulizer (every 8 h) and salbutamol nebulizer (5 mg, twice daily) were provided during pre-anesthetic evaluation in order to prepare the patient for safe anesthesia and surgery. The METs estimated by preoperative history at the preoperative evaluation visit were approximately 4 with moderate-intensity activities. He could walk on a flat surface for one or two blocks and up to two flights of stairs.\nIn the operating theater, an intravenous (IV) access, neuromuscular monitoring, and routine monitors (ECG, non-invasive blood pressure, and pulse oximetry for SpO2) were established. The patient was pre‑oxygenated with a face mask for 3 minutes. General anesthesia was induced with 2 µg/kg IV fentanyl and 2–2.5 mg/kg IV propofol. Neuromuscular blockade was achieved with 0.5 mg/kg atracurium. The trachea was intubated in a single attempt using a single-lumen cuffed tube of internal diameter 8.0 mm. The anesthesia was maintained with 50% O2, N2O, and isoflurane. Remifentanil was given continuously with a syringe infusion pump (Perfusor® Space; B. Braun, Germany) at a rate of 0.1 µg/kg/min adjusted per the patient’s heart rate.\nThe patient’s lungs were ventilated with a 50% fraction of inspired oxygen. A tidal volume of 7–10 mL/kg and respiratory rate of 10–12 breaths/min were adjusted to maintain the End-tidal CO2 between 30 and 36 mmHg. To increase the lung functional residual capacity a small amount of PEEP (5 cmH2O) was applied during the mechanical ventilation of the patient. A single dose of IV cefotaxime 1 g was administered intraoperatively.\nAbout 20 minutes before the end of the surgery, 1 g paracetamol with 100mg tramadol was infused for 15 minutes. Dexamethasone 8 mg and metoclopramide 10 g were also given intravenously.\nThe duration of FESS with bilateral frontal polypectomy was 95 minutes. All hemodynamic parameters were stable, and no additional muscle relaxant or fentanyl was required throughout the procedure. At the end of the surgery, the residual neuromuscular block was reversed with IV neostigmine 0.05 mg/kg and IV atropine 1 mg.\nLungs suctioning through the endotracheal tube and oral suctioning were performed gently. Tracheal extubation was performed when the patient was able to open the eyes and ventilate spontaneously. The emergence from anesthesia was smooth and without complications. After ~20 minutes in the post-anesthesia care unit, the patient was fully awake and pain-free (pain scale 2). The patient was then transferred to the surgical intensive care unit for 8 hours, and subsequently to the ward. An arterial blood gas analysis on room air showed pH = 7.419, oxygen concentration (PaO2) = 70 mm Hg, carbon dioxide concentration (PaCO2) = 36 mm Hg, bicarbonate ion concentration (HCO3−) = 23 mmol/L, O2 saturation = 94%, and base excess = −1 mmol/L. The postoperative period was uneventful. The patient felt subjectively “very well” and was discharged from the hospital on the ﻿second postoperative day.
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.