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 [,,,].
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).