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 Table of Contents  
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 63-65

Laparoscopic gastric bypass for morbid obesity in a patient with situs inversus totalis

Department of Surgery, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication26-Sep-2019

Correspondence Address:
Fahad Yaslam Bamaehriz
Department of Surgery, King Saudi University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SJL.SJL_1_19

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Situs inversus totalis (SIT) is a rare congenital disorder that is characterized by a complete reversal of abdominal and thoracic organs. Laparoscopic gastric surgery may pose a challenge in patients with the condition due to mirror-image anatomy. Further studies are required to assess the impact of surgery on those afflicted with this disorder. We report a case of 22-year-old female with SIT who successfully underwent laparoscopic Roux-en-Y gastric bypass. Laparoscopic surgery is feasible in patients with SIT once anatomical considerations are taken into account.

Keywords: Laparoscopic gastric bypass, morbid obesity, Roux-en-Y gastric bypass, situs inversus

How to cite this article:
Bamaehriz FY, Basardah RA, Sabbahi AA, Albalawi MM, Mustafa FA. Laparoscopic gastric bypass for morbid obesity in a patient with situs inversus totalis. Saudi J Laparosc 2019;4:63-5

How to cite this URL:
Bamaehriz FY, Basardah RA, Sabbahi AA, Albalawi MM, Mustafa FA. Laparoscopic gastric bypass for morbid obesity in a patient with situs inversus totalis. Saudi J Laparosc [serial online] 2019 [cited 2023 Jun 9];4:63-5. Available from: https://www.saudijl.org/text.asp?2019/4/1/63/251857

  Introduction Top

Bariatric surgery transformed the obesity treatment scene by conferring profound improvements in gross weight loss and reduction of burden from comorbidities.[1] Roux-en-Y gastric bypass (RYGB) surgery has long been the most practiced bariatric procedure until very recently when it was displaced by sleeve gastrectomy.[1],[2],[3],[4]

Situs inversus totalis (SIT) is a rare defect where internal organs are present contralaterally. Most of the SIT patients have a normal life expectancy and have no symptoms as a result of intact relationship between organs.[5] There are few case reports on people with SIT who underwent laparoscopic RYGB.[6],[7],[8],[9],[10],[11] Laparoscopic gastric bypass in SIT patients may constitute a special challenge to surgeons due to the converse anatomy.[6] We report a case of 22-year-old female with SIT who successfully underwent laparoscopic RYGB (LRYGB).

  Case Report Top

A 22-year-old female with SIT was admitted electively for a laparoscopic gastric bypass. Her body mass index was 46 kg/m2. Otherwise, she had no significant previous medical or surgical history.

During preoperative evaluations, ultrasound of the abdomen provided the first direct in-house visualization of her SIT. Her liver was located on the left side and her spleen was situated on the right side. A barium enema study showed features of situs inversus of the abdomen [Figure 1].{Figure 1}

Barium follow-through was performed revealing situs inversus of the gastrointestinal tract where the stomach, splenic flexure, sigmoid, and descending colon were seen on the right side and the duodenum, hepatic flexure, cecum and ascending colon were on the left side [Figure 1] and [Figure 2].{Figure 2}

After completion of the preoperative assessments, we planned to proceed with the LRYGB on the next day. The patient was positioned in supine position with her legs abducted. The surgeon stood between the abducted legs of the patient. The primary assistant stood on the left side of the patient while the monitor was placed on the opposite side. A total of five ports were used. The Veress needle was inserted at the left upper quadrant and insufflated up to a pressure of 15 mmHg. The five trocars were placed through the abdominal wall as depicted [Figure 3].{Figure 3}

The first trocar, a 10-mm laparoscopic trocar, was placed in the supraumbilical area. A second (12-mm) trocar was inserted in the upper left quadrant. A third (12-mm) trocar was placed opposite to the second trocar at the upper right quadrant. A fourth (5-mm) trocar was positioned at the subxiphoid process. Finally, a fifth (5-mm) trocar was placed lateral to third trocar.

After identifying ligament of Treitz situated to the left of the midline, the jejunum was divided 75 cm distally. The Roux limb was pulled to a length of 150 cm and J-J anastomosis was made and closed using an endostapler and white 60 reload. The stomach was divided and leaving a small 20-ml pouch. A 25 mm CEEA anvil was introduced via the oral cavity and moved until it reached the pouch. The Roux limb-free end was brought toward the gastric pouch and a side gastrojejunal anastomosis was performed. This was done using a 25-mm CEEA circular stapler with the open end of Roux limb resected by white 60 reload. Reinforcement stitches were placed and a methylene blue test was negative. The fascia layers were closed at the 10-mm and 12-mm trocar sites using 1-0 vicryl sutures. The surface skin edges were approximated and closed using 3-0 subcuticular monocryl sutures. The total operation time was 90 min. There were no intraoperative complications; the patient was discharged on day two post-operatively [Figure 4].{Figure 4}

  Discussion Top

The development of effective long-term pharmaceutical therapies to tackle morbid obesity remains elusive to date, taking a backseat to surgical intervention. RYGB, which is a type of bariatric surgery, has proven to result in long-term sustained weight loss and improvement in comorbidities.[3] SIT is a rare congenital syndrome that occurs at a rate of 1:5000 to 1:20,000 and is mainly inherited in an autosomal recessive fashion.[5] It is characterized by mirror-image reversal of normal anatomical positioning of thoracic and abdominal organs. Unlike typical RYGB which is performed with the assumption that patients' viscera are in conventional locales such as right sided liver and left-sided stomach, advanced laparoscopic surgery in patients with SIT can be arduous due to the unusual reflected anatomy.[6]

There are few cases reported on patients with SIT underwent LRYGB. The first reported case on LRYGB on an SIT patient was in 1998 by Wittgrove and Clark.[7] They documented several technical difficulties encountered such as using opposite hands when handling instruments as well as having to switch the foot used to operate the foot pedal. As a result of these challenges, operative time was almost doubled (300 min). One case report discussed the use of robot assisted LRYGB with the unexpected additional finding of mid gut rotation that necessitated the placement of an extra port. The operation went successfully with no postoperative complications.[8]

Moreover, another case series report described four patients with SIT who underwent RYGB with favorable end outcomes. However, two of these patients have not had their anatomy clearly defined which required conversion of the operation to open surgery.[9],[10]

In addition to that, with taking into account the reversed anatomy of these patients, minute details such as the mapping the ports insertion sites and adjusting the standing positions of the surgeons become critical elements for the success of the surgery. In all of these case reports, the surgical method not stated was robot-assisted or was modified so that all steps were done in a mirror-image fashion to the conventional RYGB. In other words, it was performed from the opposite side of the patient including inverting the placement of the trocar sites and standpoints of the surgeons.

Nevertheless, to our knowledge, there were no reports that describe an LRYGB that was conducted with a French position setup before our case report. However, we proceeded with our LRYGB operation with a modification, which is to use five trocars. Apart from these changes, the rest of surgery was not altered and carried out using the same adjustments made in previous LRYGB in patients with SIT.

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 initials 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

Franco JV, Ruiz PA, Palermo M, Gagner M. A review of studies comparing three laparoscopic procedures in bariatric surgery: Sleeve gastrectomy, roux-en-Y gastric bypass and adjustable gastric banding. Obes Surg 2011;21:1458-68.  Back to cited text no. 1
Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N, et al. Bariatric surgery worldwide 2013. Obes Surg 2015;25:1822-32.  Back to cited text no. 2
Buchwald H, Avidor Y, Braunwald E. Bariatric surgery a systemic review and meta-analysis. JAMA 2004;292:1724-37.  Back to cited text no. 3
Khorgami Z, Shoar S, Andalib A, Aminian A, Brethauer SA, Schauer PR, et al. Trends in utilization of bariatric surgery, 2010-2014: Sleeve gastrectomy dominates. Surg Obes Relat Dis 2017;13:774-8.  Back to cited text no. 4
Gedda L, Sciacca A, Brenci G, Villatico S, Bonanni G, Gueli N, et al. Situs viscerum specularis in monozygotic twins. Acta Genet Med Gemellol (Roma) 1984;33:81-5.  Back to cited text no. 5
McKay D, Blake G. Laparoscopic cholecystectomy in situs inversus totalis: A case report. BMC Surg 2005;5:5.  Back to cited text no. 6
Wittgrove AC, Clark GW. Laparoscopic gastric bypass for morbid obesity in a patient with situs inversus. J Laparoendosc Adv Surg Tech A 1998;8:53-5.  Back to cited text no. 7
Wall A, Feng Z, Melvin W. Robotic-assisted roux-en-Y gastric bypass in a patient with situs inversus. J Robot Surg 2014;8:169-71.  Back to cited text no. 8
Nelson L, Teixeira AF, Jawad MA. Laparoscopic roux-en-Y gastric bypass in a patient with situs inversus. Surg Obes Relat Dis 2016;12:711-3.  Back to cited text no. 9
Haque S, Koren JP. Laparoscopic roux-en-Y gastric bypass in patients with congenital malrotation. Obes Surg 2006;16:1252-5.  Back to cited text no. 10
Kassir R, Mourthadhoi F, Tiffet O, Lointier P. How do I do a laparoscopic one-anastomosis gastric bypass in a patient with situs inversus totalis. Obes Surg 2017;27:2218-9.  Back to cited text no. 11


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