Laparoscopic Hemicolectomy in Ascending Colon Cancer with Situs Inversus Totalis

Abstract

Introduction: Situs inversus totalis (SIT), occurring at a frequency of 1:5000–1:10,000 live births,1 is characterized by a complete right-to-left transposition of the thoracic and abdominal organs. Only five cases of laparoscopic colon surgery in an SIT patient have been reported. The present case describes a laparoscopic hemicolectomy necessitated by ascending colon cancer in a patient with SIT. Patient and Methods: A 54-year-old woman with ascending colon cancer was referred to our hospital. Preoperative chest radiography showed dextrocardia, and computed tomography showed complete transposition of the abdominal viscera, confirming a diagnosis of SIT. The patient, free of distant metastasis, underwent laparoscopic right hemicolectomy and radical lymphadenectomy, performed by a surgeon experienced in laparoscopic colectomies. After inducing general anesthesia, the patient was placed in a modified lithotomy position, with the operator and scopist situated on the patient's right and the first assistant on the patient's left, similar to the positioning used in laparoscopic anterior resections. A 10-mm umbilicus trocar was inserted for the camera, and 5-mm trocars were placed in the right and left iliac fossa and subcostal areas, as working ports. Trocars were inserted symmetrically, we usually use this trocar system in Rt. hemicolectomy. The ascending colon, located on left side of patient, was mobilized along with the tumor, and the ileocolic vessels and right colic artery were identified and ligated. Radical lymphadenectomy was performed after ligation of the root of the middle colic artery and the right branch of middle colic artery. The umbilical wound was extended by ∼5 cm to allow for extracorporeal anastomosis and removal of the tumor; colon reconstruction was performed using a double-stapling technique. Results and Conclusions: The operation time was 120 minutes, with minimal blood loss. The resected tumor was a 1.5×1.2-cm Bormann type II moderately differentiated adenocarcinoma. The depth of the tumor's invasion into the submucosa was classified as pT1; no lymph node metastasis or angiolymphatic invasion was observed. The patient, discharged 7 days after surgery, did not receive postoperative adjuvant chemotherapy, and was free of complications and evidence of recurrence at her 2-year follow-up examination. Previous reports on cases of laparoscopic surgery in SIT patients1–3,11–14 have described the technical difficulties associated with the abnormal anatomy. In the present case, the surgical team needed to understand the modified vessel anatomy and orientation to avoid confusing the right colic artery with the ileocolic artery. Meticulous preoperative planning, including the selection of proper locations for the trocars, positioning of surgical personnel, and selection of a well-experienced surgeon, was essential for the successful outcome. The authors did not receive any grant or financial support to perform this study. Runtime of video: 7 mins 13 secs