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Three-dimensional laparoscopic treatment of situs inversus totalis combined with gastric cancer: Case report with review of literature

1 Department of Gastrointestinal Surgery, Affiliated Hospital of Putian University, Putian, China
2 Department of Gastrointestinal Surgery, Affiliated Hospital of Putian University; Department of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian, China, Fujian Key Laboratory for Translational Research in Cancer and Neurodegenerative Diseases, Putian, China

Date of Submission06-Oct-2021
Date of Acceptance10-Jan-2022
Date of Web Publication01-Mar-2022

Correspondence Address:
Wei Lin,
Department of Clinical Medicine, Fujian Medical University, Fuzhou 350122, Fujian
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_311_21


Situs inversus totalis (SIT) is a rare congenital disease. Due to the abnormal distribution of blood vessels in the organs of SIT patients, the anatomical structure is different from that of normal people, which increases the difficulty of surgery, especially laparoscopic surgery. However, there are few reports on the treatment of SIT combined with gastric cancer surgery by three-dimensional (3D) laparoscopy. Here, we describe a case of SIT combined with gastric cancer who underwent 3D laparoscopy-assisted distal radical gastrectomy in March 2021 and with a brief review of the literature.

Keywords: Three-dimensional laparoscopy, gastrectomy, gastric cancer, situs inversus totalis

How to cite this URL:
Huang S, Lin W, Qiu X. Three-dimensional laparoscopic treatment of situs inversus totalis combined with gastric cancer: Case report with review of literature. J Min Access Surg [Epub ahead of print] [cited 2022 May 28]. Available from:

  Introduction Top

Situs inversus totalis (SIT), i.e., complete 'mirror-image transposition' of organs in the thoracic cavity, abdominal cavity or splanchnocoele, is a rare congenital disease. Due to abnormal organ and vascular distribution in SIT patients, differences in the anatomical structure compared with that in normal individuals increase the difficult of surgery, especially laparoscopic surgery.[1] However, there are few reports on the treatment of SIT combined with gastric cancer surgery by three-dimensional (3D) laparoscopy. Here, we describe a case of SIT combined with gastric cancer who underwent 3D laparoscopy-assisted distal radical gastrectomy, and then, a Billroth II gastrojejunostomy was selected to reconstruct the digestive tract in March 2021 and understand the diagnosis of and intraoperative precautions for gastric cancer and SIT to better establish treatments for this disease.

  Case Report Top

A patient, 58-year-old male, was admitted with the chief complaint of 'recurrent epigastric pain for more than 2 months.' Symptoms of pallor were observed from his appearance. Apical pulsation was observed between the fourth and fifth intercostal space on the right mid-clavicular line, with heart sounds present. The abdomen was flat, the abdominal muscles were soft and mild tenderness was reported in the upper abdomen with pressure, but no rebound pain was reported. The following findings were obtained from auxiliary examinations. Routine blood tests revealed a haemoglobin concentration of 74.0 g/L. Electrocardiography revealed (limb leads reversal and chest leads reversed to connect to the right) dextrocardia. Chest radiography indicated mirror dextrocardia [Figure 1]a. Ultrasound cardiography indicated mirror dextrocardia, with no obvious heart structure and function abnormalities. Gastrointestinal barium fluoroscopy [Figure 1]b revealed the following: (1) SIT and (2) potential space-occupying lesion in the gastric antrum. Chest + whole abdomen contrast-enhanced computed tomography (CT) [Figure 1]c showed the following: (1) SIT; (2) irregularly thickened gastric wall of the antrum, with the possibility of gastric antral carcinoma and (3) slightly larger lymph nodes (LNs) in the hepatogastric space. Electronic gastroscopy showed the following: (1) gastric antral carcinoma and (2) multiple leucoplakia in the oesophagus. Gastroscopic pathology indicated gastric antral adenocarcinoma. The diagnosis at admission was as follows: gastric antral carcinoma with blood (cT3N + M0, Stage III) and SIT. According to the concept of enhanced recovery after surgery in the multiple disciplinary treatment model, he was given a small amount of fluids on day 1 after surgery. On day 3, the patient underwent gastrointestinal barium fluoroscopy after digestive tract reconstruction [Figure 2] and was discharged on day 8. Post-operative pathology revealed the following: distal stomach: moderately differentiated Borrmann III adenocarcinoma at the stomach-lesser curvature of the gastric antrum, Lauren type, intestinal, with cancer thrombi inside the vessel and largest diameter of the mass, approximately 9.5 cm, with the subserosal layer infiltrated. No cancer was found on the upper and lower margins of the samples. Cancer metastasis was found in 8/48 LN. Immunohistochemistry (IHC) (7) of oncocytes showed the following: Cam5.2 (+), CEA (+), p53 (minority+), HER2 (0, control 3+), Ki67 (approximately 50%+) and MLH1 (−, control+), MSH2 (+), MSH6 (+) and PMS2 (−, control+). The IHC staining of DNA mismatch repair proteins (MLH1, MSH2, MSH6 and PMS2) indicated microsatellite instability, indicating a risk of Lynch syndrome. At present, the patient has received chemotherapy six times since the surgery, without tumour recurrence or metastasis and relevant surgical complications.
Figure 1: Pre-operative imaging of situs inversus totalis patient. Images of pre-operative chest X-ray film (a), gastrointestinal barium fluoroscopy (b) and abdominal computed tomography (c) shows situs inversus totalis and irregular thickening of gastric wall (red arrow)

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Figure 2: Gastrointestinal barium fluoroscopy after digestive tract reconstruction on day 3

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Surgical technique

The patient was placed in a supine position with his legs separated in a V-shape. The chief surgeon stood on the left side of the patient, one assistant stood on the right side and the assistant who held the laparoscope stood between the legs of the patient. Intraoperative laparoscopy revealed the following: the liver and gall bladder were located in the left upper abdomen, the spleen was located in the upper right abdomen, the greater curvature of the stomach fundus was located on the right side and the pylorus and duodenum were located on the left side [Figure 3]a. There was a mass (5.0 cm × 6.0 cm) in the gastric antrum, there was no transmural infiltration and there were enlarged LNs on the greater and lesser curvatures of the gastric antrum. Based on membranous anatomy, 3D laparoscopy-assisted radical gastrectomy by the 'enjoyable space' approach was employed to achieve complete tumour resection + D2 LN dissection. (1) Using the 'pick up and separate method' to dissect the lower pyloric region [Figure 3]b, the surgeon used blunt separations to enter the gastrocolic fusional fascial space and then dissected the anterior fascia of the head of pancreas along the anterior pancreatic head and separated the right gastroepiploic vein. From the lower edge to the upper edge of the pancreatic neck, the root of the right gastroepiploic artery was disconnected to achieve LN dissection in the lower pyloric region. (2) Using the 'Tent method' to separate the left area of the celiac trunk [Figure 3]c, the surgeon dissected the anterior pancreatic fascia and the mesangial lobe of the hepatoduodenal ligament to reach the common bile duct leftward. The surgeon stripped upward along the proper hepatic artery and cut off the right gastric artery at the root and then exposed the common hepatic artery, the anterior wall and the left wall of the portal vein rightward. The coronary vein was exposed and disconnected. (3) Using the 'enjoyable space separation method' to separate the right area of the celiac trunk [Figure 3]d, the surgeon made an incision at the junction of the left gastric artery and splenic artery, entered into the fusional fascial space between the gastric dorsal mesangium and retroperitoneum (i.e., the 'enjoyable space'). The enjoyable space reached the posterior edge of the splenic blood vessel downward, the oesophageal hiatus and the posterior edge of the gastro-phrenic ligament upward and the left crus of the diaphragm leftward and connected with the left side of the abdominal cavity. The left gastric artery was exposed. The enjoyable space reached the posterior edge of thespleen rightward. To complete the 3D laparoscopy-assisted radical distal gastrectomy, Billroth II gastrojejunostomy was selected to reconstruct the digestive tract, with an operation time of 220 min and an intraoperative blood loss volume of approximately 10 ml.
Figure 3: Based on membranous anatomy, laparoscopy-assisted radical distal gastrectomy. Abdominal anatomic structures viewed by laparoscopy during surgery (a). An intraoperative image showing the procedure of dissecting the lower pyloric region (b). Separating the left area of the celiac trunk (c). Separating the right area of the celiac trunk (d) RGEV – right gastroepiploic vein, RGEA – right gastroepiploic artery, GDA- gastroduodenal artery, RGV – right gastric vein, CHA – common hepatic artery, LGA – left gastric artery

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  Discussion Top

SIT is a rare congenital abnormality involving the anatomical structure of human organs and has an incidence of 1/(10,000–50,000).[2] Although the organ position changes in SIT patients, it has no effect on the health or lifespan of patients.[3] In 2003, Yamaguchi et al.[4] reported the first laparoscopic radical gastrectomy of distal gastric cancer in an SIT patient. We searched the MEDLINE and PubMed databases using the keywords (SIT) and (gastric cancer) to retrieve English literature and clinical features of SIT combined with gastric cancer published from January 2000 to July 2021 [Table 1].[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] There are 30 articles that address SIT combined with gastric cancer. All patients underwent surgery, of whom 8 underwent open abdomen procedures, 13 underwent laparoscopic surgery, 7 underwent robotic-assisted surgery or robotic surgery and 2 underwent endoscopic surgery. One patient was treated for mechanical bowel obstruction after the operation, and one patient was treated for pancreatic fistula and hepatic dysfunction. SIT may be a genetic disease, at present, the reason is still unclear. This disease is possibly caused by the inhibition of the normal flow of embryonic fluid due to a lack of cilia movement during embryonic development and incorrect rotation of the cardiac canal.[16] In addition to the malformation, patients with SIT may have a higher risk of cancer due to malfunction of the KIF3 complex.[17]
Table 1: The features of laparoscopic gastrectomy for situs inversus totalis patients with gastric cancer

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Total or distal gastrectomy plus D2 LN dissection surgery is the standard of care for progressive gastric cancer. Anatomical changes in SIT patients with gastric cancer increase the difficulty of surgical procedures, potentially affecting LN dissection. Compared with 2D laparoscopy, 3D laparoscopy can restore the real 3D anatomical structure, which is mainly reflected in the shortened operation time, the reduction of operation errors and the improvement of operation accuracy.[18] Therefore, 3D laparoscopy was used in this study. In the process of conducting complex and delicate operations and the separation of important anatomical layers, the 3D images and magnified views generated a clear surgical field more clear and a strong sense of depth. Therefore, the operation was more accurate, with less subsidiary injury, thus conforming to the advocated concepts of 'precision treatment,' 'minimally invasive treatment' and 'accelerated recovery' in the field of surgery.[19] This case report involved an SIT patient with gastric cancer. A summary of our experience follows: (1) SIT patients combined with gastric cancer present reversed organs and vessels (opposite direction). Complete pre-operative X-rays, chest and abdomen CT, gastroscopy and other related examinations can be used to locate anatomical abnormalities in a timely manner and thus derive an accurate diagnosis, avoiding misdiagnoses of abdominal diseases and reducing the risk and unpredictability of an operation. (2) The conventional position was chosen (the surgeon on the left side of the patient and the assistant on the right side). The forceps in the left hand and the ultrasonic knife in the right hand effectively establishes triangle traction without crossing in the abdominal cavity; furthermore, this position is more conducive to co-operation between the assistant and surgeon for fine dissection using the right hand. (3) The 'enjoyable space method' adheres to the concept of membrane anatomy. Effective traction resistance can be achieved through the 'tent method,' ensuring the integrity and continuity of the membrane while improving the safety of the operation. The 'enjoyable space' refers to a potential avascular fascial space that can be fully expanded, with complete separation of the dorsal mesentery of the stomach. The perigastric mesentery and vessels can be 'stood up,' allowing better identification of the course of splenic vessels and branches, thereby improving the efficiency and safety of LN dissection. Our previous research shows that the 'enjoyable space separation method' may be an optional procedure to achieve complete mesocolic excision (CME), improve the quality of surgery and increase the number of harvested LNs.[20]

  Conclusion Top

This report highlights a rare congenital disease of SIT patients with gastric cancer, 3D laparoscopy-assisted total gastrectomy for SIT patient is like a 'brain teaser,' i.e., the operation cannot follow the 'ordinary path.' During the operation, attention should be paid to the identification of anatomic structure of reversed vessels, nerves and LNs; the surgery can be safely completed only by dismissing inertial thinking.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Terakawa T, Miyake H, Tanaka H, Inoue T, Fujisawa M. Feasibility of a retroperitoneal approach as a surgical strategy for patients with situs inversus totalis: Presentation of a patient undergoing laparoscopic radical nephrectomy for renal cell carcinoma. Int Cancer Conf J 2014;3:8-10.  Back to cited text no. 1
Chen W, Guo Z, Qian L, Wang L. Comorbidities in situs inversus totalis: A hospital-based study. Birth Defects Res 2020;112:418-26.  Back to cited text no. 2
Robinson P. Situs inversus: When an incidental finding is not so incidental. J Paediatr Child Health 2017;53:715-6.  Back to cited text no. 3
Yamaguchi S, Orita H, Yamaoka T, Mii S, Sakata H, Hashizume M. Laparoscope-assisted distal gastrectomy for early gastric cancer in a 76-year-old man with situs inversus totalis. Surg Endosc 2003;17:352-3.  Back to cited text no. 4
Futawatari N, Kikuchi S, Moriya H, Katada N, Sakuramoto S, Watanabe M. Laparoscopy-assisted distal gastrectomy for early gastric cancer with complete situs inversus: Report of a case. Surg Today 2010;40:64-7.  Back to cited text no. 5
Seo KW, Yoon KY. Laparoscopy-assisted distal gastrectomy for early gastric cancer and laparoscopic cholecystectomy for gallstone with situs inversus totalis: A case report. Ann Surg Treat Res 2011;81:S34-8.  Back to cited text no. 6
Fujikawa H, Yoshikawa T, Aoyama T, Hayashi T, Cho H, Ogata T, et al. Laparoscopy-assisted distal gastrectomy for an early gastric cancer patient with situs inversus totalis. Int Surg 2013;98:266-70.  Back to cited text no. 7
Min SH, Lee CM, Jung HJ, Lee KG, Suh YS, Shin CI, et al. Laparoscopic distal gastrectomy in a patient with situs inversus totalis: A case report. J Gastric Cancer 2013;13:266-72.  Back to cited text no. 8
Sumi Y, Maehara R, Matsuda Y, Yamashita K, Nakamura T, Suzuki S, et al. Laparoscopy-assisted distal gastrectomy in a patient with situs inversus totalis. JSLS 2014;18:314-8.  Back to cited text no. 9
Ye MF, Tao F, Xu GG, Sun AJ. Laparoscopy-assisted distal gastrectomy for advanced gastric cancer with situs inversus totalis: A case report. World J Gastroenterol 2015;21:10246-50.  Back to cited text no. 10
Morimoto M, Hayakawa T, Kitagami H, Tanaka M, Matsuo Y, Takeyama H. Laparoscopic-assisted total gastrectomy for early gastric cancer with situs inversus totalis: Report of a first case. BMC Surg 2015;15:75.  Back to cited text no. 11
Shibata K, Kawamura H, Ichikawa N, Shibuya K, Yoshida T, Ohno Y, et al. Laparoscopic total gastrectomy for advanced gastric cancer in a patient with situs inversus totalis. Asian J Endosc Surg 2017;11:39-42.  Back to cited text no. 12
Kigasawa Y, Takeuchi H, Kawakubo H, Fukuda K, Nakamura R, Takahashi T, et al. Laparoscopy-assisted distal gastrectomy in a case of gastric cancer with situs inversus totalis: A case report. Asian J Endosc Surg 2017;10:47-50.  Back to cited text no. 13
Alhossaini R, Hyung WJ. Robotic assisted distal gastrectomy for gastric cancer in a patient with situs inversus totalis: With video. J Gastrointest Surg 2017;21:2144-5.  Back to cited text no. 14
Namikawa T, Maeda M, Yokota K, Tanioka N, Iwabu J, Munekage M, et al. Laparoscopic distal gastrectomy for synchronous gastric cancer and gastrointestinal stromal tumor with situs inversus totalis. In vivo 2021;35:913-8.  Back to cited text no. 15
Shimizu J, Arano Y, Adachi I, Morishita M, Fuwa B, Saitoh M, et al. Adenosquamous carcinoma of the lung in a patient with complete situs inversus. Ann Thorac Cardiovasc Surg 2011;17:178-81.  Back to cited text no. 16
Haruki T, Maeta Y, Nakamura S, Sawata T, Shimizu T, Kishi K, et al. Advanced cancer with situs inversus totalis associated with KIF3 complex deficiency: Report of two cases. Surg Today 2010;40:162-6.  Back to cited text no. 17
Almeida RD, Qureshi Y, Morawala A, Merali N, Patel B. Impact of 3D laparoscopic surgical training on performance in standard 2D laparoscopic simulation: A randomised prospective study. Surg Simul 2018;5:1-7.  Back to cited text no. 18
Memtsoudis SG, Poeran J, Kehlet H. Enhanced recovery after surgery in the United States: From evidence-based practice to uncertain science? JAMA 2019;321:1049-50.  Back to cited text no. 19
Zheng CY, Dong ZY, Qiu XT, Zheng LZ, Chen JX, Zu B, et al. Laparoscopic perigastric mesogastrium excision technique for radical total gastrectomy. Wideochir Inne Tech Maloinwazyjne 2019;14:229-36.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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2004 Journal of Minimal Access Surgery
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