A 23-year-old male patient has morbid obesity with a weight of 146.3 kg and a height of 177 cm. The calculated body mass index (BMI) was 46.7 kg/m2. The patient had previously failed to lose weight using different dietary and lifestyle modification techniques over an approximately four years period. He provided a history of dextrocardia, bronchiectasis, and chronic sinusitis with no recent flare in the last three months. He denied any history of previous surgery, smoking or alcohol consumption. He elected to have LSG to help with weight reduction.\nThe patient was evaluated by a multidisciplinary bariatric surgery team, cardiology, pulmonology, and anesthesiology. He was cleared for the planned surgery. A full assessment was conducted preoperatively including physical exam, complete blood count, biochemical profile, thyroid function test, electrocardiogram, and pulmonary function test (PFT). Additionally, imaging studies including chest x-ray, transthoracic echocardiogram, ultrasound of abdomen, computed tomography (CT) scan of sinuses, chest, abdomen, and pelvis were performed. His blood workup was normal, the electrocardiogram revealed right axis deviation (Figure ), and his radiological imaging showed evidence of SIT (Figures , -). His echocardiogram was normal except for dextrocardia and he had mild restrictive airway disease on PFT. Evidence of chronic sinusitis was seen on his sinuses CT and his chest CT showed radiological features of SI and bronchiectasis (Figure ).\nHe was admitted the night before surgery per pulmonology recommendation for preoperative monitoring. LSG was performed with the patient in the reverse Trendelenburg and French position (split-leg supine). The surgeon stood between the legs. The abdomen was accessed using veress needle technique inserted in the right upper quadrant at a mirror image of the palmer’s point after infiltration of local anesthesia. Pneumoperitoneum was achieved successfully and was maintained at 13 mmHg of intra-abdominal pressure. The veress needle was then removed and a 5-mm optical trocar was placed in the left lumbar region of the abdomen about 10-15 cm below the costal margin to avoid injuring the malpositioned liver. This was done under direct visualization using a 5 mm/zero-degree laparoscopic camera. Diagnostic laparoscopy revealed that all abdominal organs were in reverse orientation (Figure ). The spleen was located in the right hypochondriac region. The gastric fundus and its greater curvature were found under the hepatic portion located to the right of the falciform ligament. Toward the left side, in the left hypochondriac region, the gallbladder was found under the hepatic portion located to the left of the falciform ligament. Other trocars were adapted to the new position (5 mm, 10 mm, 15 mm, and 12 mm) as shown in Figure . Using blunt tip LigaSure 5 mm-37 cm device, the dissection of omentum from great curvature was done starting 4 cm from pyloric sphincter, dissection of the short gastric vessel was done safely. GIA staplers (Covidien 60 mm one black cartilage and four purples) were used to resize the stomach using intragastric bougie of 36 Fr size. Suture line clipping was done to control oozing from the staple line using 5 mm clips. A Penrose drain was inserted at the end of the procedure. No leak test was done as part of our protocol for all LSG. Estimated blood loss at the end of the surgery was less than 100 mL. Removal of the stomach stump was done through the 15 mm port incision. Evacuation of pneumoperitoneum was done gradually and skin was closed with 4-0 vicryl subcticular stitches. Local anesthesia was infiltrated at the port incisions in the end. The total duration of the operation was 68 minutes, patient was extubated uneventfully and moved to the recovery room for monitoring.\nNo early surgical or anesthetic complications were reported during or after the operation. The patient started the bariatric clear liquid diet on postoperative day 1 and he was discharged home on postoperative day 2 after removing the drain. He was readmitted after two months postoperatively due to renal colic that resolved with non-operative management. He was on a full bariatric diet by then and he lost a total of 29.3 kg with his readmission weight measured at 117 kg. He continued to do well and showing good progress with his weight loss. His postoperative weight at one year was 88 Kg with a BMI of 28.1 kg/m2.\nLiterature review\nA broad search of the published English-language medical literature utilizing Pubmed, Google Scholar, and Web of Science search engines for articles about LSG for weight loss in SI patients was performed. The following keywords were used: “obesity,” “morbid obesity,” “situs,” “situs inversus,” “gastrectomy,” “sleeve gastrectomy,” and “bariatric surgery.” The search included all articles from 1998 to May 2020. After a thorough screening, a total of 17 studies were found with 18 reported cases. Furthermore, we present a case on the same topic.\nKey information extracted and summarized in Table including our case. All cases had SIT except one case that had SI partials [] and another that had situs ambiguous []. Four cases had Kartagener syndrome [-]. One case had a planned additional procedure [] and another had an unplanned additional procedure []. Multiple port sites were used except for one case that utilized a single incision LSG technique []. Additional ports were needed in two cases [,] with four cases missing that information [,,]. French position used nine times [,,,-]. The primary surgeon stood between the legs in eight cases [,,-], to the left of the patient in six cases [,,,,] and to the right in three cases [,,]. The surgeon position was missing in two cases [,]. The mean age of cases was ~39 years (range 19-59). The patients were predominantly females (15 females and four males). The mean BMI was 45.9 kg/m2 (range 36-76). The mean operative time was ~75 minutes (range 28-202) but four authors did not report this information [,,,] and Watanabe et al. had a very long operative time due to the additional procedure []. The mean postoperative hospital length of stay was ~3 days (range 1-7) with three articles not reporting the length of stay [,,]. Preoperative workup looked similar between groups with some variations. Most of the cases had obesity-related comorbidities. Five cases had prior surgeries [,,-] with a single article that did not provide surgical history []. Only three cases had a perioperative complication [,,]. Intraoperative spleen infarction was reported by Shaheen et al. of four out of six spleens in a patient with situs ambiguous and polysplenia []. This was recognized during the time of LSG and was successfully resected. Deutsch et al. described a postoperative suture/staple line leak that was managed with endoscopic poly flex stenting []. Mosquera et al. reported upper gastrointestinal bleeding after being discharged from the hospital on postoperative day 5 []. This resolved spontaneously with clinical monitoring without the need for blood product transfusion. All of the cases achieved variable but significant postoperative weight loss. Data on weight loss were lacking in five cases [,,,].
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.