CASE REPORT

Thoracoscopic Esophagectomy and Hand-AssistedLaparoscopic Gastric Mobilization for EsophagealCancer with Situs Inversus Totalis

Yasumichi Yagi & Yutaka Yoshimitsu & Tsutomu Maeda &

Hiroshi Sakuma & Michio Watanabe & Masuo Nakai &Hiroshi Ueda

Received: 28 September 2011 /Accepted: 11 November 2011 /Published online: 29 November 2011# 2011 The Society for Surgery of the Alimentary Tract

Introduction

Situs inversus totalis (SIT) is a rare anatomic anomalycharacterized by a complete mirror image transposition ofthe thoracic and abdominal viscera relative to the situssolitus. Thereafter, surgical procedures are technically moredifficult in patients with SIT because of the differentanatomic positions of organs, especially in endoscopicsurgery. Here, we present a case of esophageal cancer withSIT and describe our experience in performing thoraco-scopic esophagectomy and hand-assisted laparoscopicgastric mobilization.

Case Report

A 73-year-old man who presented with dysphagia wasadmitted to our hospital for treatment of esophageal cancer.He had received medication for diabetes and hypertension.He did not smoke or drink alcohol. Physical examinationrevealed a temperature of 36.2°C, a pulse rate of 68 bpm,and a blood pressure of 138/72 mmHg. Nothing abnormalwas found in the respiratory system. The laboratoryfindings revealed an elevated fasting blood sugar of164 mg/dL and an increased hemoglobin A1c of 7.0%.

All other laboratory values, including tumor markers, werewithin normal limits. Dextrocardia was seen on the chest X-ray (Fig. 1a) and the electrocardiography findings weretypical of dextrocardia. Barium swallow showed a tumor,6 cm in diameter, in the middle thoracic esophagus(Fig. 1b), and the stomach was arranged in a mirror imageof the normal position (Fig. 1c). Endoscopic examinationshowed a tumor with ulceration, occupying the middle thirdof the esophagus. Histological examination of the biopsiedspecimens led to a diagnosis of moderately differentiatedsquamous cell carcinoma. Computed tomography (CT)showed the primary tumor in the middle thoracic esophagus(Fig. 2a). SIT was clearly demonstrated as a mirror imageof normal in both the thorax and abdomen (Fig. 2b). CTalso indicated some swollen lymph nodes in the middlemediastinum, but obvious metastasis was not detected inthe lung or liver. The tumor was supposed to invade theadventitia and bordered the descending aorta with noobvious invasion. We diagnosed the preoperative stage asT3N1M0, stage III according to the UICC TNM classifi-cation, supposed to be an indication of preoperativechemotherapy. For this rare anomaly, we considered thatwe should take a priority to safety and selected postoper-ative chemotherapy. The therapeutic strategy was explainedto the patient, who decided to undergo surgical treatmentfollowed by adjuvant chemotherapy.

Surgical Procedure

Video-assisted thoracoscopic (VATS) esophagectomy waspreceded by hand-assisted laparoscopic (HALS) gastricmobilization by a right-handed surgeon. Initially, the patientwas placed in a supine position. General anesthesia was

Y. Yagi (*) :Y. Yoshimitsu : T. Maeda :H. SakumaDepartment of Surgery, Houju Memorial Hospital,11-71 Midorigaoka,Nomi, Ishikawa 923-1226, Japane-mail: y-yagi@live.jp

M. Watanabe :M. Nakai :H. UedaDepartment of Gastroenterology, Houju Memorial Hospital,Nomi, Ishikawa 923-1226, Japan

J Gastrointest Surg (2012) 16:1235–1239DOI 10.1007/s11605-011-1789-y

induced through a double lumen endotracheal tube. Theoperator stood on the left side of the patient, opposite to theusual position for the standard procedure. Then, theassistant stood on the right and the camera holder stood

on the left. A vertical median incision in the upperabdomen, 7 cm in length, was made for use as a handport. Three trocars were placed in a way that the positionsof these were the mirror image of those for a patientwithout SIT (Fig. 3a). The operator inserted his right handinto the peritoneal cavity as left–right reversal of thestandard procedure. The intraperitoneal pressure was main-tained at 8–10 mmHg. Using a two flexible tip laparoscope(Olympus Optical Co. Ltd., Tokyo, Japan), the abdominalorgans were observed. There was complete transposition ofthe viscera, with the stomach and spleen lying on the rightside, and the gallbladder, the larger lobe of the liver, thececum, and the appendix on the left. The short gastricvessels and omentum were divided using laparoscopiccoagulating shears (Sono Surg; Olympus Optical Co. Ltd.,Tokyo, Japan). Gastrocolic omentum was divided withpreservation of the “right” gastroepiploic arcade, whichwould have been the left gastroepiploic arcade in a patientwithout SIT. The other major vessels, corresponding to the“left” gastric artery and vein, were divided and gastricmobilization was performed (Fig. 3b). After the extracor-poreal extraction of the stomach through the hand port, aslim gastric tube based on the greater curvature was createdwith four linear staplers (ILA50; Autosuture, Norwalk, CT,USA), dividing the stomach at the cardia. A jejunostomytube for alimentary nutrition was placed in the jejunum30 cm distally to the ligament of Treitz. Then, a drain wasinserted in the right subphrenic space through one of theport site in the right flank, and the HALS procedure wasfinished with closure of the other port sites and laparotomy.

For the second stage, the patient was placed in the rightlateral decubitus and the operator stood on the ventral sideof the patient. After intubation with selective right lungventilation, the left lung was deflated and anteriorlydisplaced by gentle compression with a retractor connectedto the Octopus retractor holder on the operator’s side. A 5-cm mini-thoracotomy was first made in the anteriolateral

a b

Fig. 2 a Chest computed tomography showed the primary tumor representing the esophageal wall thickness (arrow) and swollen lymph node(arrowhead). b Abdominal computed tomography showed the abdominal visceral transposition

a b

c

Fig. 1 a Chest X-ray film showed dextrocardia and a right aortic arch.b Esophagography showed the tumor in the middle thoracicesophagus (arrows). c Gastrography showed a mirror image of thestomach compared with a normal position

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side of the patient at the fifth intercostal space. Then, fivetrocars were placed in the left lateral side of the chest wallas shown in Fig. 4a. Consequently, the thoracoscopicprocedure was performed. Anatomical abnormalitiesthrough the left thoracotomy were observed as a mirrorimage of the normal anatomy through a right thoracotomy(Fig. 4b). First, the azygos vein arch was isolated anddivided through the lower anterior port with endovascularstapler, and the mediastinal pleura was opened on bothsides of the esophagus from the top of the thorax to thediaphragm. Subsequently, the esophageal mobilization wascarried out with the dissection of the paraesophageal tissuecontaining lymph nodes. An esophageal tumor was foundwith its superior pole situated 5 cm below the azygos veinarch. The tumor invaded the adventitia next to thedescending aorta, but it was delimited from the otherorgans. The upper esophagus was isolated and cut superiorto the azygos vein arch by using a stapler (Endo GIA 60; U.S. Surgical Corp. Norwalk, CT, USA). During radicallymph node dissection, we divided the “left” bronchialartery corresponding to a right bronchial artery in a patientwithout SIT and preserved the lung branches of the “left”vagus nerve and the “left” recurrent laryngeal nerve.Following the mobilization of the esophagus, the specimenwas removed from the surgical field. The additional lymphnode dissection was performed including radical dissectionof the upper mediastinal and paratracheal lymph nodes.

The esophago-gastric anastomosis was created using a25-mm anvil connected to a 90-cm-long polyvinyl chloridedelivery tube (Orvil, Covidien, Mansfield, MA, USA),which was passed trans-orally through an opening in theesophageal stump in a tilted position. End-to-side, doublestapling esophago-gastrostomy was completed via theintrathoracic route by joining the anvil to a circular stapler

(EEA XL; 25 mm with 4.8-mm staples, Covidien, Mans-field, MA, USA) inserted into the gastric conduit. A chesttube was placed in the pleural cavity through one of theport sites, the lung inflated, and the wound closed. Theoperating time was 390 min, and the estimated blood losswas 130 mL, which was comparable to those in orthotopicpatients.

The postoperative period was uneventful. Pathologicalexamination of the resected specimen revealed moder-ately differentiated squamous cell carcinoma with inva-sion of the adventitia and two lymph node metastases inthe upper mediastinum (pT3N1M0, LN 2/19, stage III).The proximal and distal resection margins were 2 and14 cm, respectively. Thereafter, he received adjuvantchemotherapy with two courses of 5-fluorouracil andcisplatin. No evidence of recurrence has been confirmedafter 12 months of follow-up.

Discussion

Situs inversus may involve transposition of thoracic orabdominal organs, or both. SIT denotes complete right–leftinversion of thoracic and abdominal viscera. Predispositionto SIT is a rare congenital anomaly with an incidence of 1of 10,000 to 20,000 live births1,2 and is thought to resultfrom chromosomal abnormalities which lead to a reversalof right–left polarity.3,4 Typically, persons with SIT have anormal life expectancy, and the great majority of them areunaware of their unusual anatomy until they seek medicalattention with plain chest X-ray film or ultrasonography forunrelated condition. Situs inversus itself has no pathophys-iologic significance and does not increase the prevalence ofmalignancies. In rare cases of SIT with cardiac anomalies or

A

BC

D

a

liver

stomach

esophagus

EH

RHLCSAF

b

Fig. 3 a Position of site of ports in our HALS procedure. A A 7-cmlaparotomy on the upper vertical median line; B 5-mm port placed onthe upper right portion of the umbilicus; C 5-mm port placed on theright anterior axillary line in the right flank; D 12-mm port placed forcamera on the right lower quadrant. b Intraoperative picture of the

HALS procedure showed the visceral transposition in the abdomen.Gastric mobilization performed with the assistance of the operator’sright hand through a hand port. EH esophageal hiatus, LCSlaparoscopic coagulating scissors maneuvered by the operator, RHthe right hand of the operator, AF the assistant’s forceps

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for individuals with Kartagener syndrome and severebronchiectasis, life expectancy is reduced, but this alwaysdepends on the severity of the defect and the treatmentefficiency.5 Neither Kartagener syndrome nor other anoma-lies were found in our case.

Laparoscopic surgery was technically developed afterthe introduction of laparoscopic cholecystectomy.6 Sincethen, endoscopic surgeries have been performed usually for

various malignancies. Several cases treated with endoscopicsurgery have been reported, even in patients complicated bySIT, including gastric cancer, colon cancer, rectal cancer,and appendiceal cancer.7–10 Recently, VATS esophagec-tomy with mediastinal lymphadenectomy has been estab-lished as a standard procedure for the treatment ofesophageal cancer.11,12 Review of the world literaturerevealed that only two cases with SIT had undergonetreatment for esophageal cancer. Mimae et al. reported acase of open esophagectomy13 and Yoshida et al. presenteda successful case of VATS esophagectomy with HALSgastric mobilization.14 Both of those cases were achieved incomplete mirror image opposite to the standard position. Inour case, HALS gastric mobilization was performed aheadof VATS esophagectomy. During the abdominal phase, weexperienced difficulty because the manipulation using theleft hand was troublesome and not precise for a right-handed surgeon in the mirror image anatomy. Moreover,surgical techniques need to allow for spatial adaptations ofthis condition intraoperatively. Accordingly, there may be atechnical advantage for left-handed surgeons during lapa-roscopic surgery in patients with SIT as Oms and Badiareported.15 As for the thoracic phase, the VATS procedurecould be performed as smoothly as in the regular procedure.Careful recognition of the mirror image anatomy permittedsafe radical lymphadenectomy and mobilization of thestomach in SIT, while the surgical technique itself did notdiffer from the usual situation.

A surgeon may encounter a case of SIT only once ortwice in a career because of its extremely low prevalence.Therefore, he or she should avoid potentially fatal errors bymaintaining an awareness of this condition at the beginningof surgery. Knowledge of the exact anatomy and meticu-lous preoperative planning are important factors for surgicalintervention under an unusual condition of SIT.16 Recently,CT with multiplanar reconstruction has become an estab-lished technique for noninvasive angiography. With anavailability of high resolution CT data, a wide variety oftwo-dimensional and three-dimensional reformations cannow be acquired.17 For this rare condition of SIT, detailedevaluation of mirror image anatomy can be made with CTexamination to carry out safe operative procedure. In thepresent patient, CT did not show any clear vascular

lungvertebra

AVA

Monitor

A

BC

D

E

A

b

�Fig. 4 a Position of the surgeon, a monitor, and site of left mini-thoracotomy and ports in our VATS procedure. A Third intercostalspace on mid-axilla line (5 mm); B seventh intercostal space onposterior axilla line (5 mm); C seventh intercostal space on mid-axillaline (12 mm); D tenth intercostal space on posterior axilla line(12 mm); E 5 cm left mini-thoracotomy on the fifth intercostal spaceon the anterior axilla line. b Intraoperative picture of the VATSprocedure from the caudal side toward the craniad side showed thevisceral transposition in the thorax. Thoracoscopic view showed left–right reversal versus patients without SIT as a mirror image of normalanatomy through a right thoracotomy. AVA azygos vein arch

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abnormality, which enabled us to understand the regionalanatomy. As shown in the preoperative imaging, the grossappearance of the left lung and the arrangement of thevessels and the bronchi corresponded to those normallyfound on the right side. Preoperative understanding ofregional anatomy will help us to avoid intraoperativecomplications.

VATS is effective for excellent exposure of themediastinumfor lymph node dissection. The magnifying effect of a video,by keeping the camera in close proximity to the dissection, isessential to perform the same quality of dissection as opensurgery.11,18 Furthermore, the thoracoscopic approach con-tributes to the reduction of constrictive pulmonary damage byminimizing the chest wall injury and providing the survivalequivalent to that of open surgery.12,19,20 In our case, theVATS approach allowed an identical vision shared among theoperator, the assistant, and the camera holder. It was alsohelpful for avoiding confusion of positional awareness, suchas left–right reversal or dorsal–ventral converse relation.Therefore, VATS can be recommended for patients withesophageal cancer complicated by SIT.

Recent studies demonstrated that the preoperative che-motherapy improves the survival and does not increaseintra- and postoperative complications.21 Generally, thepreoperative chemotherapy should be taken into consider-ation for the present case. However, its feasibility andsafety could not always be applicable for a patient of SIT.When the preoperative chemotherapy is combined, theVATS approach should be performed with greater care.

We encountered a very rare case of esophageal cancercomplicated by SIT with a successful treatment achievedusing endoscopic surgery. VATS esophagectomy with HALSgastric mobilization should be considered a safe, feasible, andcurative procedure for esophageal cancer with SIT. Apreoperative assessment of anatomical abnormality is essen-tial for intraoperative adaptation to the mirror image of thestandard procedure. Given enough preoperative information,imaging of the mirror-imaged anatomy should be done, andthe surgical procedure should be carried out with great care soas not to cause vessel injury and unexpected bleeding.

Competing Interests The authors declare that they have nocomplicating interests in this article.

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