A 76-year-old male with a past medical history of hypertension, hypercholesterolemia, hypothyroidism, chronic obstructive pulmonary disease, diabetes mellitus type two, obstructive sleep apnea, benign prostatic hyperplasia, cerebral vascular accident with residual right-sided weakness, and dextrocardia with situs inversus presented with an abnormal nuclear stress test. Additionally, he had a family history notable for colon cancer and myocardial infarction in his mother and a thrombotic event in his father. He had no history of significant alcohol use, tobacco use, or illicit drug use, and his past surgical interventions were not cardiovascular in nature. He originally presented at an outside hospital following a syncopal event with a 45-second loss of consciousness postmicturition. At the time, he was thought to have orthostatic hypotension, and his tamsulosin was discontinued. He also underwent a nuclear stress test for the syncopal event due to additional complaints of worsening dyspnea on exertion. Nuclear stress testing demonstrated a moderate-sized reversible anterior wall myocardial perfusion defect and a moderate-sized reversible inferolateral wall myocardial perfusion defect. He was transferred to our hospital for further evaluation of symptoms and possible left heart catheterization. Cardiac catheterization revealed the already diagnosed dextrocardia along with a new diagnosis of severe ostial left anterior descending (LAD), mid-LAD, and ostial diagonal coronary artery disease. Transthoracic echocardiography (TTE) showed trace mitral valve regurgitation, mild aortic valve regurgitation, and an ejection fraction of 60%. His underlying dextrocardia with situs inversus caused diagnostic challenge with these tests as his angiographic, radiologic, and echocardiographic images were mirror images of normal cardiac anatomy. Aggressive risk factor modification was initiated, and a consult was placed to cardiothoracic surgery for evaluation for potential coronary artery bypass grafting (CABG). He underwent three-vessel CABG on day 7 of his hospitalization with alterations in management to account for his known dextrocardia with situs inversus. The electrocardiography leads and defibrillator pads were placed in reverse orientation. A left internal jugular vein central venous catheter was placed to provide direct access to the right atrium rather than standard right-sided central venous access. The arterial line was placed in the right radial artery as opposed to the institutional standard left radial artery to accommodate for the position of the surgeon during the operation. Transesophageal echocardiography (TEE) evaluation again confirmed dextrocardia (). To obtain standardly recognized TEE images, the omniplane was adjusted to 180° for the midesophageal four-chamber view. By subtracting 60°, 90°, and 120°, midesophageal midcommissural, two-chamber, and long-axis views were then obtained. Additionally, TEE confirmation of aortic and venous cannulation required turning the probe right for the right-sided aorta and left for liver visualization, respectively. Aside from these alterations in approach, induction, intubation, and anesthetic management were conducted in normal fashion and were uneventful. He remained intubated and was taken to a cardiac intensive care unit postoperatively. A thorough sign-out was given to the intensive care unit staff to ensure understanding of his anatomy and intraoperative course. He was weaned from the ventilator and extubated on postoperative day 1 and transferred to the step-down unit on postoperative day 2. His postoperative course was complicated by urinary retention and an elevation in creatinine that trended down prior to discharge. He was discharged home in stable condition with a urinary catheter in place on postoperative day 6 that was to be removed as an outpatient. Both the patient and the responsible physicians were satisfied with the successful outcome.
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.