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.
This is a case of a 59-year-old morbidly obese female with situs inversus totalis who presented for a laparoscopic sleeve gastrectomy. Her BMI was 38 (height 4 ft 11.5 inches, weight 188.2 pounds), and she had a lifelong history of morbid obesity and obesity-related comorbidities, including obstructive sleep apnea requiring a continuous positive airway pressure machine, an elevated hemoglobin A1c (5.8) and a fasting blood glucose increasing her risk of developing diabetes mellitus, and degenerative joint disease which significantly impacted her ability to exercise. The main challenges she identified in losing weight involved eating carbohydrate rich foods, overeating during meals and limited activity due to musculoskeletal pain. The patient had made multiple attempts to lose weight through commercial dieting programs but had been unsuccessful. The patient also completed a six-month medically supervised diet through her primary care provider, which also included working closely with a bariatric registered dietician, following a strict diet of about 1800 calories/day and performing modified exercise, about 120 minutes/week. Despite these intense medical weight loss efforts, she was unable to maintain a healthy weight. The patient was motivated to try bariatric surgery after she witnessed the significant weight loss success her daughters had from this intervention. Her greatest hope from the bariatric surgery was to be healthier and to alleviate her obesity-related comorbidities.\nThe patient’s surgical history included cesarean section and evacuation of an ectopic pregnancy. She was a former smoker, quitting over 25 years ago, and has no other history of substance or alcohol use. Family history is positive for obesity, diabetes, hypertension, coronary artery disease and hypercholesterolemia. She did not take any medications, including supplements, except for Ibuprofen 800 mg 1–3/daily for musculoskeletal pain.\nThe patient underwent a comprehensive evaluation and treatment plan prior to the surgery including: psychiatric evaluation and clearance, nutritional consultation with a registered dietician, education about bariatric surgery and pre/post op expectations, routine preoperative labs, UGI, esophagogastroduodenoscopy (EGD), pulmonary function analysis, and a cardiovascular exam. Situs inversus totalis was confirmed with abdominal X-ray and CT, and echocardiogram. Pre-procedural evaluation with UGI revealed mild gastroesophageal reflux observed to the level of the distal one-third esophagus and small sliding-type hiatal hernia. EGD revealed normal esophagus and duodenum. Stomach biopsy was obtained for antral gastritis, and no helicobacter organism was identified. Abdominal ultrasound confirmed fatty liver disease. Pulmonary function analysis including spirometry, lung volumes and diffusion was normal. A pre-procedural cardiovascular exam was performed due to dextrocardia to exclude other structural cardiac abnormalities. 2-D echocardiography with M-mode demonstrated a left ventricular ejection fraction of 60%, no structural abnormalities in the aortic, pulmonic, tricuspid and mitral valve, or right and left atrium and ventricles. Color Doppler and continuous and pulse wave Doppler demonstrated mild pulmonic regurgitation and mild tricuspid regurgitation.\nThe patient discontinued the Ibuprofen more than one month before her surgery and began a low-calorie liquid diet two weeks prior to surgery. On the day of surgery, preoperative antibiotics, Cefazolin, were given within 60 minutes before the first incision. Prior to induction, the patient received 5000 units of heparin subcutaneously and sequential compression device (SCD) boots were placed for deep vein thrombosis (DVT) prophylaxis. No beta-blockers were administered. The patient was placed in the supine position and general anesthesia was induced. A Foley catheter was placed and the patient was supported with positioning devices including: arms on padded arm boards, gel pad under left axilla, footboard with gel pads, hover mat and a bariatric safety belt over patient’s thighs. The abdomen was then prepped and draped in the standard surgical fashion.\nA Veress needle was used in the right upper quadrant to access the abdomen and insufflation was created to 15 mmHg. Veress was removed and replaced with a 5 mm trocar and the scope was placed. Additional trocars were placed in the following position: right and left 5 mm lateral trocars, right and left 12 and 15 mm supra-umbilical trocars. The placement of all retractors and graspers was adjusted accordingly to the mirror image anatomy of the intraabdominal organs. The primary surgeon was positioned on the left side of the patient and the assisting surgeon on right side of the patient. Situs inversus totalis was confirmed with the majority of the liver oriented to the patient’s right, spleen on the right, greater curvature of the stomach on the right and gallbladder on the left.\nThe operating table was placed in the reverse Trendelenburg position. The patient’s right-sided half of the liver was retracted cephalically using a Nathanson retractor to expose the vicinity of the esophageal hiatus. The peritoneum over the cardia was incised using the Ethicon Harmonic scalpel, and the plane between the cardia and the left crus of the diaphragm was opened to expose the right diaphragmatic crus. No hiatal hernia was present. A point 5 cm proximal to the pylorus along the greater curvature of the stomach was marked corresponding to the incisura angularis just proximal to the crow’s foot of Latarjet’s nerve. The vessels along the greater curvature and all the short gastric vessels were sealed and divided using the Ethicon Harmonic scalpel, freeing the greater curvature and the fundus of the stomach. A 42-French bougie was placed and oriented towards the antrum along the lesser curvature (Figure ). The stomach was stapled and divided alongside the tube in a vertical fashion towards the angle of His (Figures -).\nAn Ethicon Echelon Flex triple staple line power stapler with a total of one black, three green, and one gold staple loads was used. All staple loads were 60 millimeters in length with staple line bio-absorbable reinforcement. Hemostasis at the external staple line was achieved (Figure ). The stomach was removed from the abdomen via the left-sided 15 mm trocar (Figures , ). Intraoperative endoscopy was performed using a 5 mm Olympus Ultrathin gastroscope revealing no areas of stenosis, internal staple line bleeding, nor staple malformation or leak seen. Total operation time was 108 minutes. There were no post-operative complications.\nPost-operative care included pain management and DVT prophylaxis with SCD, heparin and early ambulation four hours post-surgery. A UGI was performed on post-op day 2 with normal findings for a post-bariatric surgery evaluation and clear fluids were started. The patient was discharged on post-op day 3 without any complications. Upon discharge, the patient had a treatment plan that was previously discussed that included instructions for diet and medications, including vitamin supplementation and antacids. At her three-month follow-up, the patient was still without complications and very pleased with her weight loss of 46.2 lbs, weighing 142 lbs (BMI 29).