Laparoscopic Distal Gastrectomy in a Patient with Situs Inversus Totalis: A Case Report
A 68-year-old male underwent a screening EGD in September of 2012. There were no remarkable findings in the routine laboratory examination including tumor markers, except for an elevated creatinine level (1.95 mg/dl). This was due to the chronic kidney disease and hypothyroidism for which he was being treated. Despite these conditions, preoperative risk assessment indicated tolerability of a laparoscopic operation. The patient had no history of abdominal surgery. His preoperative BMI was 23.55 kg/m2, and a chest x-ray film revealed dextrocardia. EGD showed a hyperemic nodular lesion on the mid antrum anterior wall. Biopsy confirmed well-differentiated adenocarcinoma (). EUS showed definite involvement of the submucosa, but proper muscle layer invasion was suspected. CT showed SIT with no other remarkable findings (). There were no vascular anomalies, and no metastasis or invasion into adjacent structures, so the clinical stage was cT2N0M0. TLDG with delta anastomosis and D1+ lymph node dissection was scheduled. The operator stood on the same side as if there was no SIT throughout the operation. A flexible scope was used through the 12 mm trocar made on the umbilicus. Two 12 mm trocars and two 5 mm trocars were used, making a V shape (). Exposure of the hepatoduodenal ligament and the lesser omentum was achieved with the retraction of the falciform and the left lobe of the liver using a single suture technique.\nPartial omentectomy was performed about 4 cm from the gastroepiploic arcade. The left gastroepiploic vessels were ligated near the fundus and omentectomy was performed along the greater curvature. The right gastroepiploic vessels were then ligated, and the right gastric artery was ligated onto the root from the common hepatic artery. A linear stapler was inserted through the 12 mm trocar on the right side of the patient, and the duodenum was divided just distal from the pylorus. The left gastric artery and the coronary vein were ligated during lymph node dissection along the superior border of the pancreas. After completing lymph node dissection along the lesser curvature, D1+ lymph node dissection was completed. The stomach was divided at the angle portion by a linear stapler and delta-shaped anastomosis was performed (). The resected specimen was delivered through the umbilicus, with extension of the incision. The operation time was 117 minutes and the estimated blood loss was 50 ml, without any intraoperative complications. There were no postoperative complications and the patient was discharged 5 days after the operation.\nThe final pathology reported a 3.2×1.2×0.1 cm sized, well-differentiated adenocarcinoma, localized within the lamina propria. Fifty-nine lymph nodes were retrieved, none of which contained a metastasis. The final pathology was pT1aN0, stage IA.