Bariatric Surgery Unit (Obesity Center), Humanitas Research Hospital, Via Manzoni, 56, 20089, Rozzano, Milan, Italy.
Surg Endosc. 2018 Jan;32(1):516. doi: 10.1007/s00464-017-5734-3. Epub 2017 Aug 4.
Obesity is an epidemic on the rise [1]. The number of bariatric procedures has increased worldwide. Laparoscopic sleeve gastrectomy (LSG) is a valid therapeutic option, leading to a sustained weight loss with a low complication rate [2]. Situs viscerum inversus totalis (SIT) is the complete transposition of all the abdominal organs, occurring in about 1 in 10,000 people [3]. Laparoscopic approach in SIT is challenging due to the mirror image anatomy.
We present the case of a 41-year-old man with a body mass index of 46.4 kg/m (131 kg; 1.68 m) previously diagnosed with SIT who has undergone LSG.
In this video, we show a LSG performed in a patient with SIT. There were no changes in the technique compared to the "standard anatomy." The patient was placed on the operative table in anti-trendelenburg position with legs abducted. The surgeon stood between the legs while the assistant was on the right side of the patient and the scrub nurse on the opposite side. A 12-mm trocar was inserted with a direct technique in the right lateral flank. Carbon dioxide insufflation was done under vision. Other three trocars (12, 10, and 5 mm) were positioned in the left lateral flank, supraumbilical, and subxiphoid areas, respectively. Gastroepiploic dissection started at 5 cm from the pylorus up to the right crus. After the insertion of a 36-Fr boogie, an accurate stapling of the stomach was performed. The proximal side of the sleeve was reinforced with a non-absorbable suture. Titanium clips were placed leading to a complete haemostasis. The procedure lasted 45 min. The patient followed a "fast-track" protocol afterwards, with no changes in the perioperative workup compared to "standard anatomy" patients. He was discharged on day 2 postoperatively and no complication occured in the perioperative period.
SIT is a rare condition leading to a mirror image that can be challenging for a laparoscopic surgeon. LSG is feasible and safe also for morbidly obese patients with SIT, not requiring any change in the surgical technique and perioperative management, as long as the surgeon is well beyond the learning curve.
肥胖是一种不断上升的流行疾病[1]。全球范围内的减重手术数量有所增加。腹腔镜袖状胃切除术（LSG）是一种有效的治疗选择，可导致持续的体重减轻，且并发症发生率低[2]。全内脏反位（SIT）是所有腹部器官的完全转位，发生在大约每 10000 人中的 1 例[3]。由于镜像解剖结构，SIT 中的腹腔镜方法具有挑战性。
我们介绍了一例 41 岁男性患者的病例，他的体重指数为 46.4kg/m（131kg；1.68m），此前被诊断为 SIT，并接受了 LSG 治疗。
在这个视频中，我们展示了一例在 SIT 患者中进行的 LSG。与“标准解剖结构”相比，技术上没有变化。患者被放置在手术台上，采用反 Trendelenburg 体位，双腿外展。外科医生站在两腿之间，助手站在患者右侧，刷手护士站在对面。在右侧侧腹以直接技术插入 12mm 套管针。在直视下进行二氧化碳充气。另外三个套管针（12、10 和 5mm）分别放置在左侧侧腹、脐上和剑突下区域。胃网膜从幽门 5cm 处开始向右侧胃皱襞分离。插入 36Frboogie 后，准确地对胃进行吻合。用不可吸收缝线加固袖套的近端。放置钛夹以达到完全止血。手术持续了 45 分钟。患者随后遵循“快速通道”方案，与“标准解剖结构”患者相比，围手术期检查没有变化。他在术后第 2 天出院，围手术期无并发症发生。
SIT 是一种罕见的情况，会导致镜像，这对腹腔镜外科医生来说具有挑战性。LSG 对于 SIT 的病态肥胖患者也是可行且安全的，只要外科医生已经超越了学习曲线，就不需要改变手术技术和围手术期管理。
