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 55-year-old female patient presented to surgical out-patient department (OPD) with chief complaints of pain and left hypochondrium for the last 3 days accompanied by nausea and vomiting. She presented a big dilemma to the attending surgeon as all the clinical signs and symptoms pointed towards symptomatic cholelithiasis, but the pain in the left hypochondrium totally contradicted the diagnosis. It was only with the help of radiological investigation reports that we were able to confirm it as a case of situs inversus totalis. Her chest X-ray typically depicted dextrocardia and spiral computed tomography (CT) scan showed transposition of all major abdominal organs. Echocardiography was carried out and revealed normal cardiac parameters with an ejection fraction of 60%.\nPre-anaesthetic evaluation revealed Mallampatti class II patient with a slight retrognathia, a pulse rate of 74/min, blood pressure of 130/78 mmHg and normal profile of laboratory investigations. She had a history of intermittent respiratory tract infections, especially during the winter season. At present, the patient had no systemic complaint pertaining to any organ system except for the gall bladder disease. A decision to operate the patient was taken and she was posted for open cholecystectomy.\nTablet ranitidine 150 mg and tablet alprazolam 0.25 mg were administered as premedication a night before and 1 h prior to the surgical procedure with a sip of water. In the operation theatre, a good intravenous (IV) access was secured with a wide bore cannula. Induction of anaesthesia was achieved with O2, isoflurane, propofol 120 mg, butorphanol 1 mg and succinylcholine 100 mg. During induction, we encountered masseter spasm immediately after the administration of succinylcholine, which lasted for approximately 45 s, and disappeared spontaneously, but we were able to ventilate the patient with bag and mask during this episode. Intubation was extremely difficult as the larynx was placed quite anteriorly and the laryngoscopic view could be best labelled as Cormack Lehane grade-III. Maintenance of anaesthesia was carried out with injection vecuronium and low concentration of isoflurane in oxygen and nitrous oxide mixture. The peri-operative period was characterized by frequent copious secretions from the respiratory tract that had to be cleared regularly for smooth ventilation. Inj. Hydrocortisone 100 mg was given prophylactically to prevent any bronchospasm. The surgical procedure was smooth and uneventful, and lasted for about 1 h. At the end of surgery, inj. Neostigmine and glycopyrrolate were administered but extubation was delayed as the patient developed prolonged post-operative apnoea. Therefore, extubation was performed only after establishing the return of all protective airway reflexes and establishment of regular breathing pattern. Infiltration of surgical incision site was carried out with 8 ml 0.375% of ropivacaine. The recovery period and hospital stay were uneventful and the patient was discharged in a satisfactory condition on the eighth post-operative day and was called for follow-up after 2 weeks.