Laparoscopic resection for rectal cancer and cholecystectomy for patient with situs inversus totalis.

Situs inversus totalis (SIT) is a rare congenital anomaly presenting with complete transposition of thoracic and abdominal viscera. Laparoscopic surgery for either rectal cancer or gallbladder diseases with SIT is rarely reported in the literature. A 39-year-old woman was admitted to hospital owing to rectal cancer. She was diagnosed with SIT by performing radiography and abdominal computed tomography scan as a routine preoperative investigation. We performed laparoscopic resection for rectal cancer successfully in spite of technical difficulties caused by abnormal anatomy. One year later, she was diagnosed with cholecysticpolyp, and we performed laparoscopic cholecystectomy for her uneventfully. With this case, we believe that performance by an experienced laparoscopic surgeon, either laparoscopic resection for rectal cancer or cholecystectomy with SIT is safe and feasible.

INTRODUCTION

Situs inversus totalis (SIT) is a rare autosomal recessive inherited disorder with the incidence ranging between 1:20,000 and 1:10,000.[1] It typically presents with complete transposition of thoracic and abdominal viscera, which is also called “mirror people.” Rare incidence and anatomic abnormality lead to great difficulties in diagnosis and treatment of surgical diseases for patients with SIT.[2] In this study, we presented one case of laparoscopic resection for rectal cancer and cholecystectomy with SIT, and discussed its feasibility and safety.

CASE REPORT

A 39-year-old woman, with no previous medical history, was admitted to hospital in May 2012 because of bloody stool for 1 year. Physical examination revealed apical impulse located in the 5th intercostal space, right midclavicular line. Chest radiography showed dexiocardia. Body mass index was 19.7 kg/m2. Serum carcinoembryonic antigen and cancer antigen 19–9 level were both normal. Colonoscopy demonstrated a mass 5 cm away from the anal verge, and biopsy's result confirmed a moderately differentiated rectal adenocarcinoma. Abdominal computed tomography (CT) scan revealed situs inversus [Figure 1] and rectal cancer invading through the muscularis propria with no obvious lymph node enlargement. The preoperative staging of rectal cancer was cT3N0M0, Stage IIA. After two courses of “XELOX” neoadjuvant therapy, the rectal cancer became smaller obviously.

Figure 1

Computed tomography scan revealed situs inversus.

In spite of potential technical difficulties caused by abnormal anatomy, we decided to perform a laparoscopic procedure for her. Informed consent was signed, and laparoscopic resection for rectal cancer was performed in July 2012. The operation was performed under general anesthesia, and the patient was placed in lithotomy position. Contrary to usual laparoscopic resection for rectal cancer, the right-handed surgeon and camera surgeon were positioned on the left side of the patient, while the first assistant surgeon was on the right. Pneumoperitoneum was established using the veress needle technique. A 10-mm port, below the umbilicus for a 30° telescope, was first inserted. Another three trocars were placed for manipulation at the opposite site of McBurney's point, left and right lateral side of the rectus abdominis at the level of umbilicus, respectively. Laparoscopic exploration showed complete transposition of abdominal viscera: The stomach and spleen were located in the right upper abdomen, whereas the liver and gall bladder were in the left upper abdomen, and sigmoid colon was in the right lower abdomen. The sigmoid mesocolon and mesorectum were dissected along the inner side of the ureter by harmonic scalpel, and inferior mesenteric artery was explored on the left side of the vein. The vessel and lymphatic vessel were ligated at the root of the inferior mesenteric vessel with polymer clips [Figure 2]. Then the rectum was transected, and finally, the sigmoidorectostomy was completed with a 29 mm intraluminal stapler intracorporeally.

Figure 2

Ligation of inferior mesenteric vessel.

The surgery was performed successfully. The operative time was 175 min and blood loss was only 10 mL. The patient resumed oral intake after 2 days and was discharged 7 days postoperatively. No complication or mortality occurred. The number of harvested lymph nodes was 22. Based on histopathologic examination, a 2.5 cm × 1.5 cm, muscular layer, moderately differentiated adenocarcinoma (ypT2N0M0, Stage I) was diagnosed. Radiotherapy (50 Gy in 25 fractions to the pelvis) and another four courses of “XELOX” chemotherapy were applied after surgery.

One year later, an abdominal CT scan was arranged for her during regular follow-up. The result revealed no recurrence. However, 1.5 cm × 0.6 cm cholecystic polyp was found, so laparoscopic cholecystectomy was performed for her in September 2013.

The operation was performed under general anesthesia. The right-handed surgeon and camera surgeon were positioned on the right side of the patient, while the assistant surgeon was on the left. A 10-mm port below the umbilicus for a 30° telescope was first inserted. Another 10-mm (medial epigastric) and two 5-mm ports (midclavicular and anterior axillary line on the left) were inserted, respectively. Laparoscopic exploration showed gall bladder located in the left upper abdomen. The Calot's triangle was dissected carefully, and then the cystic duct and artery were ligated with polymer clips gradually [Figure 3]. Then the gall bladder was separated from its bed and extracted in a retrieval bag through the medial epigastric port. The operative time was 55 min and blood loss was 5 mL. The postoperative hospital stay was 3 days. The pathologic examination was adenomatous polyp.

Figure 3

Ligation of cystic duct and artery.

DISCUSSION

SIT is a rare anomaly caused by embryonic development disorder, with the incidence ranging between 1:20,000 and 1:10,000.[1] It typically presents as dexiocardia and abdominal situs inversus, while the organ function is normal. Surgery for abdominal diseases with SIT is usually difficult due to abnormal anatomy.

Recently, laparoscopic surgery for patients with SIT has been performed. Oms and Badia[2] reported a potential advantage for left-handed surgeons during laparoscopic surgery for patients with SIT. However, right-handed surgeons should not hesitate to perform this procedure. The most frequently reported in laparoscopic surgery for the patient with SIT are laparoscopic cholecystectomy and appendectomy.[3456] However, laparoscopic surgery for gastric or colorectal cancer with SIT is even rarely reported,[789] because this procedure requires a thorough preoperative planning and excellent experience in laparoscopic surgery.

In this study, we performed laparoscopic resection for rectal cancer and laparoscopic cholecystectomy for a patient with SIT successively. Before performing surgery for rectal cancer, we deeply discussed the unusual anatomy of this patient and decided to perform laparoscopic surgery with opposite positions of surgeons. Both surgeon and camera surgeon were positioned on the left side of the patient, while the first assistant surgeon was on the right to perform laparoscopic resection for rectal cancer. The surgery detail was similar. We dissected the sigmoid mesocolon and mesorectum along the inner side of the ureter first and then ligated the inferior mesenteric artery. The sigmoidorectostomy was completed with an intraluminal stapler intracorporeally. Although the opposite anatomy increased technical difficulties and prolonged operation time, the procedure was still performed uneventfully with little intraoperative bleeding and fast postoperative recovery.

One year later, this patient was diagnosed with cholecystic polypus. With the previous experience, we performed laparoscopic cholecystectomy with expertise. The blood loss was little; operation time and postoperative hospital stay were similar to surgery for usual patients.

CONCLUSION

In spite of technical difficulties caused by abnormal anatomy, we should not hesitate to perform a laparoscopic procedure for the patient with SIT. Performed by experienced laparoscopic surgeon, either laparoscopic resection for rectal cancer or cholecystectomy with SIT is safe and feasible.