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 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.