Laparoscopic Distal Gastrectomy in a Patient with Situs Inversus Totalis: A Case Report
In February 2012, a 52-year-old male was diagnosed with early gastric cancer through a screening esophagogastroduodenoscopy (EGD). The patient visited our hospital for further evaluation and surgical treatment, if needed. He had been diagnosed with SIT about 30 years previously, but he had not developed any specific disease until this point. His body mass index (BMI) was 22.8 kg/m2, and he had no other underlying disease and no family history of SIT or stomach cancer. The patient had no history of surgery, except for a right inguinal hernia repair in 2007. Initial vital signs were stable, and a systemic review and physical examination revealed nothing of note. Laboratory examination, including tumor markers, likewise showed no abnormal findings. The chest x-ray film suggested dextrocardia, and an EGD image of the patient indicated an opposite orientation of the pylorus and the stomach (). The lesion was 2 cm proximal to the pylorus. Preoperative clipping was performed 1 cm proximal (angle, superjacent, low body anterior wall) and 1 cm distal (prepyloric antrum) to the ill-defined early gastric cancer lesion on the mid-antrum lesser curvature. Poorly differentiated adenocarcinoma was found on biopsy. Endoscopic-ultrasonography (EUS) showed submucosal invasion but no definite perigastric lymphadenopathy. Computed tomography (CT) showed transposition of the organs (). There was also focal wall thickening and enhancement in the lesser curvature of the prepyloric antrum with multiple, tiny lymph nodes in the perilesional and perigastric space.\nAs there were no distant metastases or visible invasion into adjacent organs, the clinical stage was cT2N0M0, and we decided to perform LADG with D1+ lymph node dissection. Prior to surgery, abdominal angiographic CT with three-dimensional (3D) reconstruction was performed to uncover any variations and to verify the exact structures and locations of the vessels. There were two major artery variations: a replacing common hepatic artery from the superior mesentery artery, and 2 branches from the left gastric artery ().\nLaparoscopic surgery was performed. We decided to use the same placement of ports as we do for normal patients (). However, we used a 12 mm trocar instead of a 5 mm trocar for the 1st assistant, in case the position of the operator changed. Intraoperatively, there was an obvious transposition of the abdominal organs (). Partial omentectomy was done followed by ligation of the left gastroepiploic vessels. While dissecting the area around the right gastroepiploic vessels and the suprapancreatic portion, the surgeon tried to move to the opposite side, but found that it was easier to perform this dissection on the usual side. The epigastric incision was primarily used as a port for liver retraction before extracorporeal anastomosis. With the liver retracted by the 1st assistant, the lesser omentum was opened. This patient had a common hepatic artery originating from the superior mesenteric artery, so the right gastric artery came from the celiac trunk. Due to its small size, careful dissection and ligation were performed (). Lymph node dissection was performed around the celiac axis and along the lesser curvature. The two branches of the left gastric artery were identified and were found to match the preoperative 3D reconstruction image. The radiologist confirmed the anatomic variation in the surgical field and both branches were safely ligated at the root (). After the D1+ lymph node dissection, an extension of the epigastric port site was made for extracorporeal anastomosis. The now freely movable stomach was brought up to the incision. A modified extracorporeal, double-stapling, end-to-end Billroth I anastomosis procedure was performed (). The operation time was 220 minutes and there were no intraoperative events, with an estimated blood loss of 100 ml. There were no immediate postoperative complications, and the patient was discharged eight days after the operation without any complications.\nThe final pathology showed a 3.3×2.2×0.3 cm sized, poorly differentiated Borrmann type 3 lesion with invasion limited to the muscularis propria. There was no metastasis in any of the 29 retrieved lymph nodes. The final stage was pT2N0, Stage 1B according to the American Joint Committee on Cancer 7th edition.