A laparoscopic pancreaticoduodenectomy for pancreatic adenocarcinoma in a patient with situs inversus totalis

Two Cases of Single-Incision Laparoscopic Surgery for Sigmoid Colon and Rectal Cancer in Situs Inversus Totalis

INTRODUCTION

Situs inversus totalis (SIT) is a rare congenital disorder characterized by the complete inverted transposition of the thoracic and abdominal viscera. This anatomical variation complicates laparoscopic surgery, and there are currently no reports of single-incision laparoscopic surgery (SILS) for patients with sigmoid colon cancer or rectal cancer with SIT.

CASE PRESENTATION

We performed SILS on 2 patients with sigmoid colon and rectal cancers who also had SIT. The first case involved a 64-year-old woman with sigmoid colon cancer. A 3.5 cm umbilical incision was made, and SILS was performed using a single-port surgical device with three 5 mm trocars placed in the incision. The sigmoid colon was resected with a linear stapler, which required switching from a 5 mm trocar to a 12 mm trocar. Laparoscopic anastomosis was performed using the double-stapling technique. The second case involved an 81-year-old man with dual cancers located in the sigmoid colon and lower rectum, 8 cm from the anal verge. The abdominal approach was performed using SILS, similar to the first case, along with a transanal total mesorectal excision (TaTME) from the perineum by 2 teams. Anastomosis was performed laparoscopically using a single-stapling technique. Neither patient experienced postoperative complications, and both remained free of recurrence at 42 and 7 months, respectively.

CONCLUSIONS

SILS is a feasible approach for patients with sigmoid colon cancer or rectal cancer and SIT.

BILE DUCT INJURY REPAIR IN A PATIENT WITH SITUS INVERSUS TOTALIS

BACKGROUND

Bile duct injury (BDI) causes significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life, and should be managed in centers with expertise. Anatomical variants may contribute to a higher risk of BDI during cholecystectomy.

AIMS

To report a case of bile duct injury in a patient with situs inversus totalis.

METHODS

A 42-year-old female patient with a previous history of situs inversus totalis and a BDI was initially operated on simultaneously to the lesion ten years ago by a non-specialized surgeon. She was referred to a specialized center due to recurrent episodes of cholangitis and a cholestatic laboratory pattern. Cholangioresonance revealed a severe anastomotic stricture. Due to her young age and recurrent cholangitis, she was submitted to a redo hepaticojejunostomy with the Hepp-Couinaud technique. To the best of our knowledge, this is the first report of BDI repair in a patient with situs inversus totalis.

RESULTS

The previous hepaticojejunostomy was undone and remade with the Hepp-Couinaud technique high in the hilar plate with a wide opening in the hepatic confluence of the bile ducts towards the left hepatic duct. The previous Roux limb was maintained. Postoperative recovery was uneventful, the drain was removed on the seventh post-operative day, and the patient is now asymptomatic, with normal bilirubin and canalicular enzymes, and no further episodes of cholestasis or cholangitis.

CONCLUSIONS

Anatomical variants may increase the difficulty of both cholecystectomy and BDI repair. BDI repair should be performed in a specialized center by formal hepato-pancreato-biliary surgeons to assure a safe perioperative management and a good long-term outcome.

Surgical challenges during open pancreaticoduodenectomy in a patient with situs inversus totalis: A rare case report and literature review

Background

Situs inversus totalis is a rare congenital anomaly defined by a mirror-image of thoracic and abdominal viscera. Discrete cases of situs inversus totalis and its association with gastrointestinal tumors have been reported. Here we report the first case of pancreatic-head serous cystadenoma in patient with situs inversus totalis.

Case presentation

A 68-year-old woman presented with an abdominal mass that appeared four months ago. She was otherwise asymptomatic and her physical examination was unremarkable. Chest X-ray revealed dextrocardia. CT scan confirmed situs inversus totalis with an irregular, clear border, heterogenous pancreatic-head mass measuring 11 cm. Laboratory studies were within the reference range and pancreatic tumor markers were normal. We performed an elective open pancreaticoduodenectomy followed by an end-to-side pancreaticojejunostomy, an end-to-side choledochojenunostomy, and a side-to-side gastrojejunostomy. The immediate postoperative course was uneventful, and she was discharged four days later without any complications. Four-month of follow-ups revealed no recurrent or relapsed disease.

Discussion

Although the steps of the Whipple procedure are almost the same in SIT patients. The main differences during the operation in SIT patients are the anatomical variations and how the surgeon will cope with them to avoid any mistakes.

Conclusion

The surgeons should improve their skills and gain control in both hands to easily adjust with the anatomic variations of situs inversus totalis and reduce the operation time and the associated risk of long operation time.

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Situs inversus totalis (SIT) is a rare congenital anomaly defined by a mirror-image of thoracic and abdominal viscera.

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Pancreaticoduodenectomy is more demanding and challenging to perform in patients with situs inversus totalis.

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Surgeons should have a complete state of focus and take extreme care at each step during the operation.

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Surgeons should improve their skills and gain control in both hands to adjust with the anatomic variations of SIT.

Robotic-assisted pulmonary lobectomy with lung cancer in a patient with situs inversus totalis

Background

Situs inversus totalis (SIT) is a relatively rare congenital abnormality in which the major thoracic and abdominal visceral organs are reversed from their usual positions. In patients with SIT and bronchial carcinoma, surgical difficulty increases sharply. It has been reported that the video-assisted thoracic surgery (VATS) still poses the operator to a challenge situation. The similarity of surgical positions and the flexibility of the mechanical arm in robotic surgery, may be beneficial to SIT patients due to reducing technical difficulties. Here, we present a first case of SIT patient with lung cancer, in which Da Vinci robot-assisted thoracic surgery (RATS) was performed successfully.

Case presentation

A 66-year old patient, previously diagnosed with SIT since childhood, came to our hospital with two pulmonary nodules in his left lung field. The bigger one had increased somewhat for the last 2 years of follow-up. Software Mimics was preoperatively carried out to analyze anatomical variations. RATS was conducted to complete left upper lobectomy and left middle wedge resection. The patient had no intraoperative complications and was discharged day 5 after the operation.

Conclusions

This is the first report of a successful robot-assisted lung cancer resection in a patient with SIT. In such challenging cases as lung cancer and rare anomaly as SIT, RATS is more advantageous and suitable than VATS with the help of software Mimics utilized for 3D reconstruction, which can identify the anatomical abnormalities and facilitate the surgical procedures.

Da Vinci robot-assisted pancreato-duodenectomy in a patient with situs inversus totalis: A case report and review of literature

BACKGROUND

Situs inversus totalis (SIT) is an extremely rare congenital malformation characterized by mirror displacement of the thoracoabdominal organs such as the heart, liver, spleen, and stomach. Herein, we describe a patient with SIT complicated with cholangiocarcinoma who underwent successful pancreaticoduodenectomy with the assistance of a da Vinci robot.

CASE SUMMARY

A 58-year-old female presented to the hospital with paroxysmal pain in her left upper abdomen, accompanied by jaundice and staining of the sclera as chief complaints. Imaging examination detected a mass at the distal end of the common bile duct, with inverted thoracic and abdominal organs. Endoscopic retrograde cholangiopancreatography forceps biopsy revealed the presence of a well-differentiated adenocarcinoma. The patient successfully underwent robotic-assisted pancreaticoduodenectomy; the operation lasted 300 min, the intraoperative blood loss was 500 mL, and there were no intraoperative and postoperative complications.

CONCLUSION

SIT is not directly related to the formation of cholangiocarcinoma. Detailed preoperative imaging examination is conducive to disease diagnosis and also convenient for determining the feasibility of tumor resection. Robot-assisted pancreaticoduodenectomy for SIT complicated with cholangiocarcinoma provides a safe, feasible, minimally invasive, and complication-free alternative with adequate preoperative planning combined with meticulous intraoperative procedures.