Laparoscopic sleeve gastrectomy on a morbidly obese patient with situs inversus totalis: A case study and systematic review of the literature

doi:10.1016/j.orcp.2016.12.003

Obesity Research & Clinical Practice

Volume 11, Issue 5, Supplement 1, September–October 2017, Pages 144-151

https://doi.org/10.1016/j.orcp.2016.12.003 Get rights and content

Summary

Introduction

Situs inversus totalis (SIT) is a condition where the internal organs or organ systems are located contra-laterally to the norm, forming a mirror image. Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure that has become more common over the last two decades. We report on a morbidly obese patient with SIT who underwent a successful LSG.

Case report

A 54-year-old female morbidly obese patient (136 k; 167 cm; body mass index (BMI): 48 kg/m²) was admitted for bariatric surgery. She had congenital SIT, a history of open cholecystectomy and, despite implementing the suggestions of the dietitian and endocrinologist, she had failed to lose weight. A standard LSG was performed successfully using the French method. The patient's postoperative course was uneventful and she was discharged on the 5th postoperative day. She is now in the 4th month with a weight loss of 30 kg.

Discussion

SIT is a rare congenital condition, occurring in 1/10,000 to 1/50,000 live births. Organ function is generally normal, although it may sometimes be accompanied by respiratory or cardiovascular anomalies. Although undertaking LSG on morbidly obese patients with SIT may seem a daunting proposition at first, experienced laparoscopic surgeons can manage this operation with success.

Conclusion

Although SIT is a rare congenital condition, LSG can be performed safely and effectively.

Introduction

In recent years, morbid obesity has emerged as one of the most important public health issues worldwide, due to increased co-morbidities, including diabetes mellitus, hypertension, metabolic syndrome, and psychosocial impairment with a reduced life expectancy [1]. In morbidly obese patients whose body mass index is above 40 kg/m² or higher than 35 kg/m² with associated co-morbid diseases [2], [3], bariatric surgery has proved to be the treatment of choice. LSG is one of the most commonly performed bariatric procedures, offering a satisfactory weight loss and improvement in hypertension and metabolic and endocrine disorders such as dyslipidemia and diabetes mellitus type 2 [3], [4].

Situs inversus is classified in two types: situs inversus partialis (SIP) and SIT. In the case of SIP one or more organs in the abdominal or thoracic cavities is transposed; SIT, however, is a very rare clinical condition in which all organs and tissues are transposed to the opposite side of the body. SIT occurs in 1 in every 10,000 to 50,000 births [5]. Although SIT does not seem to affect normal health or life expectancy, the reverse anatomy may cause technical difficulties when performing surgical procedures [6], [7], [8]. Here, we report a successfully performed LSG in a morbidly obese patient with SIT and introduce a systematic review of the literature.

Section snippets

Research protocol and strategy

Study identification and data extraction were realized by searching Pubmed, Google Scholar and Researchgate scientific literature databases, using the following search terms: ‘obesity’, ‘morbid obesity’, ‘bariatric surgery’, ‘obesity surgery’, ‘laparoscopic sleeve gastrectomy’, ‘laparoscopic adjustable gastric band’, ‘laparoscopic gastric bypass ‘situs inversus totalis’. In addition, additional studies were manually examined for relevant references by trained researchers. The article’s title,

Case report

A 54-year-old female patient with morbid obesity was electively admitted to our clinic for LSG procedure. She was 1.67 m tall and weighed 138 kg (BMI: 48 kg/m²). Her medical history revealed SIT, open cholecystectomy, Type 2 diabetes and osteoarthritis. On physical examination, a left subcostal incision scar was seen in the left upper quadrant and cardiac apex beat was found in the right hemi-thorax. Dextrocardia was detected on a plain chest X-ray (Fig. 1). The ear, nose and throat (ENT)

Literature review

Investigation of the English language medical database, using Pubmed, Google Scholar and Research-gate, revealed a total of 21 cases of SIP and SIT between 1998 and April 2016. 13 patients had SIT; 8 patients had SIP (Fig. 5) and Kartegener syndrome was diagnosed in one patient. Most of the patients were female (71.4%, 15 cases). The median age was 39 years (min–max: 19–52); median BMI was 45.3 kg/m² (min–max: 35–76). Laparoscopic Roux-en-Y gastric bypass (LRYGB) was performed in 10 patients;

Discussion

Obesity is one of today’s most important problems worldwide, with obesity and obesity-related co-morbidities increasing over the last three decades [1]. Medical treatment options such as diets, drugs or endoscopic intra-gastric balloon insertion do not usually achieve sufficient weight loss [1], [2]. As a result, bariatric surgical procedures have recently become more popular solutions for morbid obesity [3]. LSG is one of the most commonly performed bariatric procedures since it can be

Conclusion

SIT is a very rare congenital anomaly. However, LSG can be performed safely and effectively in morbidly obese patients with situs inversus by experienced laparoscopic surgeons.

Conflict of interest

None declared.

References (26)

L. Nelson et al.
Laparoscopic Roux-en-Y gastric bypass in a patient with situs inversus
Surg Obes Relat Dis
(2016)
C. Stier et al.
Are laparoscopic bariatric procedures feasible in morbidly obese patients with situs inversus? A report of 2 cases and a brief review
Surg Obes Relat Dis
(2014)
E.M. Pauli et al.
Laparoscopic placementof an adjustable gastric band in a super-super obese patient with situs inversus
Surg Obes Relat Dis
(2008)
J.Y. Park et al.
Clinical experience of weight loss surgery in morbidly obese Korean adolescents
Yonsei Med J
(2014)
J.B. Dixon et al.
Bariatric surgery: an IDF statement for obese Type 2 diabetes
Diabet Med
(2011)
D. Nocca et al.
Impact of laparoscopic sleeve gastrectomy and laparoscopic gastric bypass on HbA1c blood level and pharmacological treatment of type 2 diabetes mellitus in severe or morbidly obese patients. Results of a multicenter prospective study at 1 year
Obes Surg
(2011)
S. Çetinkünar et al.
The effect of laparoscopic sleeve gastrectomy on morbid obesity and obesity-related comorbidities: a cohort study
Ulus Cerrahi Derg
(2015)
N.R. Varano et al.
Situs inversus: review of the literature. Report of four cases and analysis of the clinical implications
J Int Coll Surg
(1991)
L. Brunetti
Scuola di Anatomia Patologica della R. Università di Padova. La tannizzazione dei tessuti animali
(1878)
O. Reish et al.
A homozygous Nme7 mutation is associated with situs inversus totalis
Hum Mutat
(2016)

H.D. Rott

Kartagener's syndrome and the syndrome of immotile cilia

Hum Genet

(1979)

J.M. Catheline et al.

Laparoscopic sleeve gastrectomy for a super-super-obese patient with situs inversus totalis

Obes Surg

(2006)

L. Genser et al.

Trans-umblical single incision laparoscopic sleeve gastrectomy in a patient with situs inversus totalis and Kartegener syndrome: video report

Obes Surg

(2015)

Cited by (9)

Sleeve gastrectomy on a patient with situs Inversus: A case report
2023, International Journal of Surgery Case Reports
Bariatric surgery is one of the methods used to treat obesity. Performing Laparoscopic Sleeve Gastrectomy (LSG) on patients with Situs Inversus Totals (SIT) could be very challenging and has no standard protocol yet. The aim of this case report is to describe our experience in performing laparoscopic sleeve gastrectomy in situs inversus patients. The article has been reported in line with the SCARE criteria.
Our patient is a 33-year-old woman with a body mass index (BMI) of 45 kg/m2, known case of polycystic ovarian syndrome (PCOS) and secondary infertility. She was admitted to the hospital for LSG for weight reduction surgery. Preoperative investigations showed that the patient had SIT. Subsequently, we successfully performed LSG on this patient without intraoperative or postoperative complications. The patient was discharged home two days post-operation and given a follow-up appointment after two weeks.
Literature review states that SIT occurs once in 10,000 to 50,000 births. Therefore, it can serve as a challenge when performing any operation such as LSG.
A good understanding and a well-planned approach prior to any surgery will ease the performance of the procedure and lead to better outcomes for the patient post-operation.
Laparoscopic sleeve gastrectomy in a patient with Situs Inversus Totalis: A case report and literature review
2022, Annals of Medicine and Surgery
& Importance: Laparoscopic sleeve gastrectomy (LSG) is a widely accepted and effective bariatric surgery for achieving weight loss in patients with extreme obesity. Performing this surgical procedure in patients with congenital anatomical changes including situs inversus (SI) is a challenge for the surgical team. In this condition, the orientation of intra-abdominal organs is the mirror image of those in normal populations.
Herein, we present a 29-year-old female with situs inversus totalis who successfully underwent an LSG surgery with proper weight loss post-operatively and no early and late complications.
By reviewing the literature for patients with SI undergoing the same procedure, all patients achieved significant weight loss. Three out of nineteen cases experienced complications which were controlled without significant morbidity or mortality.
Conclusion: we concluded that LSG will be a safe and effective surgery for the treatment of extreme obesity in SI patients, if the condition is diagnosed preoperatively.
Laparoscopic sleeve gastrectomy in a patient with situs inversus totalis: A case report
2020, Journal of Taibah University Medical Sciences
Citation Excerpt :
Skin preparation and draping was performed as per surgical protocol, and carbon dioxide insufflation was started using a Veress needle at Palmar's space and maintained at a pressure of 12 mmHg. After adequate gas insufflation, an 11 mm bladeless trocar was inserted into the supra-umbilical region midpoint between the umbilicus and xiphoid process.1 A 10 mm, 30° scope used for examination of the peritoneal cavity, which revealed a right-sided stomach and spleen, while the liver and gallbladder were on the left side.
Laparoscopic cholecystectomy in a patient with situs inversus totalis after videolaparoscopic sleeve—Case report
2020, International Journal of Surgery Case Reports
Citation Excerpt :
An additional challenge in this case was the fact that the patient had a previous laparoscopy due to gastroplasty performed. Wittgrove et al. [11] were the first surgeon to describe a videolaparoscopic gastric bypass in 1998 and since then several authors have been describing several techniques to try to standardize the best technique in these cases [12–14]. The presence of adhesions related to the surgery hardly interfered with the Calot triangle dissection, but the way they presented themselves required the attention of the entire surgical team.
Situs inversus totalis is the technical term used when there is a complete transposition of all organs to the opposite side referring to classical embryogenic orientation. Laparoscopic cholecystectomy is one of the most performed surgeries in the world.
We report the case of a 61-year-old female patient who had previously undergone videolaparoscopic gastroplasty 7 months ago, who developed refractary biliary colic and underwent videolaparoscopic cholecystectomy.
The surgical technique is challenging in these cases, specially because of the mirror findings in relation to the original technique. An additional challenge in this case was the fact that the patient had a previous laparoscopy due to gastroplasty performed. The presence of adhesions related to the surgery hardly interfered with the Calot triangle dissection, but the way they presented themselves required the attention of the entire surgical team.
Although uncommon, laparoscopic cholecystectomy can be performed in a situs inversus patient with ease, even in the presence of a previous surgical approach.
Laparoscopic Roux-en-Y gastric bypass in a patient with situs inversus totalis: Case report, technical tips and review of the literature
2018, International Journal of Surgery Case Reports
Citation Excerpt :
Laparoscopic Roux-en-Y gastric bypass (LRYGB) was performed in 5 patients (22.7%) [1,4,12–14]; Laparoscopic banded Roux-en-Y gastric bypass (LBRYGB) in one patient [9]; Robotic assisted RYGB (RRYGB) in one patient [11]; and laparoscopic adjustable gastric banding (LAGB) in 5 patients [2,5–8]. Laparoscopic sleeve gastrectomy (LSG) was performed in 7 patients [3,10,12,15,16,19,21]; modified duodenal switch (LSG + duodeno-jejunal bypass, and stomach-intestine pylorus sparing; SIPS) in two cases [17,18], and there was a single case of Omega loop gastric bypass or mini gastric bypass that was published with a Supplementary video [20]. Complications were documented in 2 cases [5,10].
Laparoscopic Roux-en-Y gastric bypass (LRYGB) has proven over the years to be one of the most effective bariatric procedures. It is highly technical, and therefore is mostly performed by bariatric and metabolic surgeons. Although Situs Inversus Totalis (SIT) is a very rare congenital condition, surgeons do occasionally have to operate intra-abdominally on those patients, consequently facing some challenges related to the unusual anatomy.
We describe a rare case of LRYGB for chronic morbid obesity on a 43 year old patient with pre-operative diagnosis of situs inversus totalis without Kartagener’s syndrome, using slight modification from the usual technique based on anatomical correlation without the need to change the surgeon’s position or switching trocar placements as described in previous papers. This could help surgeons in general reduce the potential challenges faced when performing such procedure.
Situs Inversus Totalis is a rare congenital condition, but surgeons in general do encounter those patients throughout their career. This rare condition should not solely be an indication for an open approach as minimally invasive surgery, whether laparoscopic or robotic, is safe and should still be considered the standard of care approach. Bariatric surgery is one of the most technical intra-abdominal procedures mainly due to the patients’ body habitus, different instrumentations used, and the different anastomoses created. Gastric bypass and bariatric surgery in general can be safely performed on patients with SIT without the need for major adjustment to the surgeon’s position, trocar placement or instruments used.
Bariatric and Metabolic Surgery in Patients with Situs Inversus: a Systematic Review
2023, Obesity Surgery

View all citing articles on Scopus

View full text

Case ReportLaparoscopic sleeve gastrectomy on a morbidly obese patient with situs inversus totalis: A case study and systematic review of the literature

Summary

Introduction

Case report

Discussion

Conclusion

Introduction

Section snippets

Research protocol and strategy

Case report

Literature review

Discussion

Conclusion

Conflict of interest

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Clinical experience of weight loss surgery in morbidly obese Korean adolescents

Yonsei Med J

Bariatric surgery: an IDF statement for obese Type 2 diabetes

Diabet Med

Impact of laparoscopic sleeve gastrectomy and laparoscopic gastric bypass on HbA1c blood level and pharmacological treatment of type 2 diabetes mellitus in severe or morbidly obese patients. Results of a multicenter prospective study at 1 year

Obes Surg

The effect of laparoscopic sleeve gastrectomy on morbid obesity and obesity-related comorbidities: a cohort study

Ulus Cerrahi Derg

Situs inversus: review of the literature. Report of four cases and analysis of the clinical implications

J Int Coll Surg

Scuola di Anatomia Patologica della R. Università di Padova. La tannizzazione dei tessuti animali

A homozygous Nme7 mutation is associated with situs inversus totalis

Hum Mutat

Kartagener's syndrome and the syndrome of immotile cilia

Hum Genet

Laparoscopic sleeve gastrectomy for a super-super-obese patient with situs inversus totalis

Obes Surg

Trans-umblical single incision laparoscopic sleeve gastrectomy in a patient with situs inversus totalis and Kartegener syndrome: video report

Obes Surg

Case Report
Laparoscopic sleeve gastrectomy on a morbidly obese patient with situs inversus totalis: A case study and systematic review of the literature