Open Access Case Report

Laparoscopic Sleeve Gastrectomy in Situs

Inversus Totalis: A Case Report
Review began 02/29/2024
Hamad S. Alsubaie 1 , Wadha S. AlOtaibi 2
Review ended 06/14/2024
Published 06/18/2024 1. Department of Surgery, College of Medicine, King Saud University, Riyadh, SAU 2. Department of General Surgery,
© Copyright 2024 King Saud University Medical City, Riyadh, SAU
Alsubaie et al. This is an open access
article distributed under the terms of the
Corresponding author: Hamad S. Alsubaie, [email protected]
Creative Commons Attribution License CC-
BY 4.0., which permits unrestricted use,
distribution, and reproduction in any
medium, provided the original author and
source are credited. Abstract
DOI: 10.7759/cureus.62610
Obesity prevalence is increasing with the modern lifestyle. Bariatric surgery is an excellent method to
sustain weight reduction and the most commonly performed surgery is laparoscopic sleeve gastrectomy
(LSG). The laparoscopic approach can be challenged in certain conditions such as situs inversus totalis (SIT).
We report a 38-year-old gentleman with class II obesity known to have SIT. After complete preoperative
preparation, we performed LSG with no complications. The main difficulty of performing any surgical
procedure for SIT patients is the reversed anatomy. It is essential to highlight the importance of anatomy for
surgeons. Proper preoperative anatomy assessment along with the surgeon's experience is the key element
to perform LSG or any bariatric laparoscopic procedure in rare conditions such as SIT.

Categories: Anatomy, General Surgery

Keywords: situs inversus abdominals, situs inversus totalis, situs inversus, bariatric surgery, laparoscopic sleeve
gastrectomy, obesity

Introduction
Obesity prevalence is increasing worldwide with the modern lifestyle [1]. Bariatric surgery is an excellent
method to sustain weight reduction when indicated and with good patient selection [2]. Laparoscopic sleeve
gastrectomy (LSG) is the most performed bariatric surgery accounting for almost 50% of all the practiced
bariatric surgeries [2]. LSG has a good weight reduction profile especially when combined with behavioral
and nutritional counseling [3-6].

The laparoscopic approach in bariatric surgeries can be challenged in certain conditions such as situs
inversus totalis (SIT) [3]. This congenital condition is a transposition of the thoraco-abdominal organs as
opposed to their regular position, in which major organs are reversed [7]. The first reported laparoscopic
procedure in SIT patients was a laparoscopic cholecystectomy reported in 1991 [8]. Thereafter, a variety of
techniques were reported in the literature, which included but not limited to mirror placement of
laparoscopic ports, referral of patients to left-handed surgeons, considering single-port surgery, and
depending on thorough preoperative imaging [9].

Case Presentation
We report a 38-year-old gentleman with class II obesity and a body mass index of 36.24. He is a known case
of hypothyroidism on medication and is known to have SIT. Also, he had undergone patch repair of a
ventricular septal defect six years ago. He has been a smoker for three years now. The patient reported a
long history of failure of achieving substantial and durable weight loss despite following up with a dietitian
for dietary plans, a trial of medical therapy by an endocrinologist, and also underwent gastric balloon
placement five years back.

He was admitted electively for a thorough preoperative assessment and preparation. For cardiologic
clearance, he underwent electrocardiogram (ECG) and transthoracic echocardiogram (TTE). His ECG showed
sinus rhythm with first-degree atrioventricular (AV) block, right atrial enlargement, left axis deviation, and
T-wave abnormality, concerning for anterior ischemia. On the other hand, his TTE revealed normal size and
function of the left ventricle, no residual leak, and an ejection fraction of more than 55%. He also underwent
a chest X-ray with the finding of dextrocardia (Figure 1).

How to cite this article

Alsubaie H S, AlOtaibi W S (June 18, 2024) Laparoscopic Sleeve Gastrectomy in Situs Inversus Totalis: A Case Report. Cureus 16(6): e62610.
DOI 10.7759/cureus.62610
 FIGURE 1: Chest X-ray showing dextrocardia with air fluids levels in the
right upper quadrant of the abdomen

The patient was declared fit for surgery by the cardiologist. To complete his preoperative planning we needed
to delineate his anatomy, so we decided to do an X-ray abdomen, X-ray fluoroscopy barium swallow and
ultrasound (US) of the abdomen. The X-ray abdomen showed air fluids levels in the right upper quadrant and
the X-ray fluoroscopy was unremarkable but for a complete situs inversus with reversed anatomical
positions (Figures 2-4).

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 FIGURE 2: Abdominal X-ray showing mirror presentation of the intra-
abdominal organs.

2024 Alsubaie et al. Cureus 16(6): e62610. DOI 10.7759/cureus.62610 3 of 11

 FIGURE 3: Fluoroscopy barium swallow showing mirror presentation of
the intra-abdominal organs.

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 FIGURE 4: Fluoroscopy barium swallow showing mirror presentation of
the intra-abdominal organs.

Also, the US abdomen showed no pathology and reported left-sided liver, right-sided spleen, no gallbladder
stones or biliary dilatation, no hydronephrosis or obvious renal stones, and no ascites could be appreciated.

The perioperative course was unremarkable. We performed LSG, the patient's position was split-leg position,
French position (thighs in abduction with the surgeon positioned between the legs) as of all our regular
cases. Although the surgeon is right-handed, he can work with both hands. We inserted four trocars, three
5mm and one 15mm trocar. We introduced pneumoperitoneum through veress needle on left upper
quadrant, then 5mm optic trocar inserted supraumbilical and slightly to the left, 5mm subxiphoid trocar
inserted, another 5mm trocar inserted on the right mid-clavicular line around five fingerbreadth above the
umbilical level, and finally 15mm trocar inserted on the left mid-clavicular line at the level of the umbilicus
(Figure 5).

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 FIGURE 5: Laparoscopic sleeve gastrectomy (LSG) trocar sites
(A) Patient with regular anatomy. (B) Patient with situs inversus totalis (SIT).

Designed by Najd AlZahrani, medical student at King Saud University, Riyadh, Saudi Arabia.

The intra-operative findings were similar to the pre-operative findings and no complications were
encountered (Figure 6).

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 FIGURE 6: Laparoscopic view of mirror presentation of the intra-
abdominal organs.

We report no prolongation of operative time, all cases performed on the same day had approximately similar
operative time. The patient's postoperative course was uneventful, and he was discharged on day 1
postoperative. The patient presented to our clinic for the first follow-up, two weeks post-operative. He was
doing well with no active complaint. He was following our post-operative protocol as explained to him
before the discharge. Upon examination the wounds healed well and his abdomen is soft. He lost about 7 kg
in the first two weeks. The pathology report revealed mild chronic active gastritis, helicobacter like
organisms, and no signs of metaplasia or malignancy. The patient received clarithromycin-based therapy for
14 days post-operative. And lastly, three months after surgery, the patient presented to our clinic for a
regular follow-up with a BMI of 31.

Discussion
Situs inversus totalis (SIT) is a rare congenital condition where organ function is generally normal, and as in
our patient, this condition is frequently associated with respiratory or cardiovascular anomalies [7]. The
main difficulty of performing any surgical procedure for SIT patients is the reversed anatomy. It is essential
to highlight the importance of anatomy for surgeons [3-6]. Laparoscopic bariatric surgery in patients with
SIT was reported in 27 cases in the literature (Table 1). The predominant procedure that was performed on
those patients was LSG on a total of 16 cases, six cases underwent laparoscopic Roux-en-Y gastric bypass,
five cases underwent laparoscopic adjustable gastric banding, only one case had laparoscopic sleeve
gastrectomy with duodenojejunal bypass, and also one case had single incision laparoscopic sleeve
gastrectomy (Table 1).

Body Mass Index Operation Time

Principle Author - Age/ Preoperative Surgical Postoperative
Pre-operation (Mean Operation Previous Operation
Year (Reference) Gender Diagnostic Method Procedure Complications
(kg/m 2) Time)

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 Aziret M - 2016 [3] 54/F 48 kg/m 2 X-ray chest 105 min Open cholecystectomy LSG No

Salerno A - 2018
41/M 46.4 kg/m2 NA 45 min LSG LSG No
[5]

Froylich D - 2018
47/F 51 kg/m 2 VFSE/X-ray chest 62 min NA LSG No
[6]

USG/X-ray
Stier C - 2014 [10] 39/M 44 kg/m 2 76 min (50–93) No LRYGB No
chest/gastroscopy/ECG

USG/X-ray
Stier C - 2014 [10] 51/F 54.2 kg/m2 61 min (16–87) No LSG No
chest/gastroscopy/ECG

Deutsch - 2012 Suture Line

39/F 42 kg/m 2 Abdominal CT NA Open Gastric Banding LSG
[11] Leakage

Ahmed AR - 2006 ECG/X-ray chest/CT

47/F 58.1 kg/m2 160 min (105) No LRYGB No
[12] scan

Wittgrove AC -
38/F 47.8 kg/m2 ECG/X-ray chest 300 min (159) No LRYGB No
1998 [13]

Tsepelidis D -
51/F 43 kg/m 2 NA 120 min (NA) No LRYGB No
2015 [14]

Catheline JM - ECG/gastroscopy/X-ray
19/M 76 kg/m 2 NA No LSG No
2006 [15] chest/USG

Trans-
Genser L - 2015 ECG/X-ray chest/CT
52/F 49 kg/m 2 52 min (45–60) No umbilical No
[16] scan
SILSG

Ersoy E - 2005 ECG/gastroscopy/X-ray

33/F 53 kg/m 2 NA No LAGB No
[17] chest/USG

Samaan M - 2008
29/M 56 kg/m 2 ECG NA No LAGB Band erosion
[18]

Matar ZS - 2008 ECG/VFSE/X-ray

28/M 51 kg/m 2 NA No LAGB No
[19] chest/ USG

Taskin M - 2008 LAGB +

20/F 44.9 kg/m2 ECG/X-ray chest/USG 90 min BIB No
[20] LC

Pauli EM - 2008 X-ray chest/chest and

47/F 60 kg/m 2 105 min No LAGB No
[21] abdominal CT scan

Yazar FM - 2015 ECG/ gastroscopy/X-

21/F 41.8 kg/m2 78 min (28–60) No LSG No
[22] ray chest/USG

Taha MH - 2017
33/F 42.7 kg/m2 ECG/VFSE/X-ray chest 50 min No LSG No
[23]

Taha MH - 2017
41/F 41.7 kg/m2 ECG/VFSE/X-ray chest 75 min No LSG No
[23]

Bawahab MA - ECG/ ECHO/X-ray

30/F 36 kg/m 2 28 min Cesarean Section LSG No
2020 [24] chest barium meal test

Almussallam B - ECG/X-ray
23/M 46.7 kg/m2 68 min No LSG No
2021 [25] chest/Echo/CT-CAP

ECHO/X-ray, CT Cesarean section,

Villalvazo Y - 2018
59/F 38 kg/m 2 abdomen and 108 min evacuation of an ectopic LSG No
[26]
chest/EGD pregnancy

Poghosyan T -
58/F 39 kg/m 2 EGD 130 min Total thyroidectomy LRYGB No
2020 [27]

Burvill A - 2019
25/F 40 kg/m 2 NA 35 min No LSG No
[28]

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 Watanabe A - Appendectomy,
46/F 40.3 kg/m2 ECG/CT-CAP/EGD 202 min LSG/DJB No
2016 [29] hysterectomy

Atwez A - 2018
43/F 50 kg/m 2 NA 180 min NA LRYGB No
[30]

Amirbeigi A - 2022
29/F 40 kg/m 2 ECG/CT-CAP 75 min No LSG No
[31]

Ali B - 2019 [32] 48/F 41 kg/m 2 CT-CAP/EGD 75 min No LSG No

TABLE 1: A brief review of the studies of bariatric surgeries with situs inversus totalis
BIB: bioenteric intragastric balloon, BMI: body mass index, CT: computed tomography, DM: diabetes mellitus, ECG: electrocardiography, HT:
hypertension, LAGB: laparoscopic adjustable gastric banding, LC: laparoscopic cholecystectomy, LRYGB: laparoscopic Roux-en-Y gastric bypass, LSG:
laparoscopic sleeve gastrectomy, NA: not available, OSAS: obstructive sleep apnea syndrome, SILSG: single incision laparoscopic sleeve gastrectomy,
USG: abdominal ultrasonography, VFSE: video fluoroscopic swallowing exam, EGD: esophagogastroduodenoscopy, DJB: Duodeno-Jejunal bypass.

Preoperative workups for SIT in most of the cases were ECG, X-ray chest, and abdominal CT scans. Mirroring
of trocar locations and intraoperative French position were the most reported surgical techniques in LSG
[8,10,15,22,24,26]. However, Deutsch et al. and Burvill et al. reported using supine position [11,28]. We
managed to perform LSG with mirroring of two tracer sites and with French surgeon position. Using French
position was our surgeon's preference. As per the literature and clinical experience in modern dedicated
minimally invasive surgery suite, the body posture of the neck and trunk along with the orientation of the
head did not differ significantly between the French and American positions [33]. In terms of tissue exposure
both positions are considered to be safe and efficient depending on surgeon preference and training [33].
Interestingly, a randomized clinical trial comparing French and American positions in LSG showed the
American position to have a lower physical and mental impact on the surgeon [34].

Also, it was reported that prolonged operative time and the need of additional trocar are indicators of a
challenging laparoscopic procedure [22]. In our case, the operative time was similar to our regular cases and
we did not require additional trocar. All reported cases in the literature were completed laparoscopically.
Leakage after LSG was reported once [11]. Our patient was followed up for three months so far, and he
succeeded to lose weight and did not develop any post-operative complications as reported in a handful
number of cases in the literature [10,13-15,24,28].

Conclusions
In conclusion, anatomy delineation prior to any surgical procedure is important. With good preoperative
planning, performing LSG for SIT patients is safe and not technically challenging.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Wadha S. AlOtaibi, Hamad S. Alsubaie

Acquisition, analysis, or interpretation of data: Wadha S. AlOtaibi, Hamad S. Alsubaie

Drafting of the manuscript: Wadha S. AlOtaibi, Hamad S. Alsubaie

Critical review of the manuscript for important intellectual content: Wadha S. AlOtaibi, Hamad S.
Alsubaie

Supervision: Hamad S. Alsubaie

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial

2024 Alsubaie et al. Cureus 16(6): e62610. DOI 10.7759/cureus.62610 9 of 11

 relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

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