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Laparoscopic distal gastrectomy for advanced gastric cancer with situs inversus totalis: a case report
Surgical Case Reports volume 8, Article number: 182 (2022)
Situs inversus totalis (SIT) is a relatively rare condition, in which the thoracic and abdominal organs are reversed or mirrored from their normal positions. Here, we reported a case of a patient with SIT and advanced gastric cancer with lymph node metastasis who underwent laparoscopic distal gastrectomy (LDG).
A 67-year-old man with SIT was clinically diagnosed with T3N2M0 advanced gastric cancer located in the middle gastric body. Three-dimensional reconstruction of computed tomography angiogram revealed that the common hepatic artery originated from the superior mesenteric artery. The patient underwent LDG with D2 lymph node dissection and Roux-en-Y reconstruction. The postoperative course was uneventful.
This case report showed that LDG could be safely performed on a patient even under complex conditions, such as advanced gastric cancer with lymph node metastasis with SIT and vascular anomalies.
Situs inversus totalis (SIT) is a relatively rare autosomal recessive congenital anomaly found in one per 8000 to 25,000 persons  and is characterized by the position of the cardiopulmonary and abdominal organs being inverted. Although a recent randomized controlled trial (RCT) revealed that laparoscopic gastrectomy for gastric cancer had become a standard procedure especially for clinical stage I cancer , this procedure is technically demanding owing to the anatomical anomalies in patients with SIT. There are several reports on laparoscopic gastrectomy for SIT; however, only a few reports have presented laparoscopic gastrectomy for patients with advanced gastric cancer with SIT [3,4,5,6], which is considered a complex procedure because of the additional requirement for D2 lymph node dissection. Previous reports regarding the management of advanced disease pertained to patients with SIT who did not have lymph node metastases on clinical assessment. Here, we report a case of laparoscopic distal gastrectomy (LDG) with therapeutic D2 lymph node dissection for clinical metastatic lymph nodes and Roux-en-Y reconstruction for advanced gastric cancer with SIT and review the previous literature on this subject.
A 67-year-old man with SIT was diagnosed with advanced gastric cancer using Gastrointestinal endoscopy, performed at an outside hospital during investigation for epigastric discomfort. The patient was subsequently referred to our hospital for further evaluation. He was diagnosed with SIT at the age of 17 years. Gastrointestinal endoscopy showed an elevated lesion with an ulcer (type 2) on the posterior lower body of the stomach (Fig. 1a), and histological examination revealed moderately differentiated tubular adenocarcinoma. Double-contrast imaging revealed a lesion in the deformed posterior wall of the middle gastric body (Fig. 1b). Additionally, computed tomography (CT) revealed inverted abdominal organs and irregular thickening of the gastric wall with swollen lymph nodes and no distant metastasis (Fig. 2a, b). A three-dimensional (3D) reconstruction image of CT angiography showed complete transposition of vessels and branching of the common hepatic artery (CHA) directly from the superior mesenteric artery (SMA) (Fig. 3). The tumor marker levels were within the normal ranges. The patient was preoperatively diagnosed with a clinical T3N2M0 Stage IIIA according to the third edition of Japanese Classification of Gastric Carcinoma . Consequently, LDG with D2 lymph node dissection and Roux-en-Y reconstruction were planned.
Surgeons with the Endoscopic Surgical Skill Qualification System (ESSQS)  accreditation participated in this operation. During the operation, the surgeon stood on the left side of the patient, opposite the usual side for surgery at our hospital. Four trocars were inserted in the left and right subcostal and lateral abdominal regions. The laparoscopic view showed an inversus of the intra-abdominal organs, including the stomach and the spleen (Fig. 4a). After the position of the spleen was confirmed, ligation of the left gastroepiploic vessels with partial omentectomy was performed. During the operation, the usage of the dominant hand was often the opposite of the usual manner. For example, the non-dominant hand of this operator handled the energy device shown in Fig. 4b. While dissecting the region around the right gastroepiploic vessels, the surgeon moved to the right side. However, we found that sometimes it was technically easier to perform this dissection from the opposite side, and the surgeon occasionally alternated between the right and left sides. In lymph node dissection of the infrapyloric area, the pancreas head, duodenum, and transverse colon mesenterium are considered anatomical landmarks. Therefore, each landmark was confirmed during the procedure, and finally the right gastroepiploic vein and artery were identified and ligated (Fig. 4c).
Next, the surgeon moved to the left side, and the lateral segment of the liver was retracted instrumentally. The lesser omentum was resected, and the right gastric artery from the proper hepatic artery (PHA) was identified and ligated. As this patient had the CHA originating from the SMA, the anatomical landmarks of lymph node dissection in the suprapancreatic area were considered the upper border of the pancreas, portal vein, and left gastric artery (LGA) from the celiac axis (Fig. 4d). In addition, an enlarged lymph node of 3 cm diameter was found along with the coronary vein and LGA and therapeutic lymph node dissection was performed without touching the enlarged lymph node (Fig. 4e). Then, lymph node dissection was performed along the dorsal plane of the proximal splenic artery (SPA) and was performed for another enlarged lymph nodes along the lesser curvature up to the esophagogastric junction (Fig. 4f). Finally, a Roux-en-Y antecolic gastrojejunostomy was performed under minilaparotomy (Fig. 4g). Notably, the operation time was 446 min, and the blood loss was 3 mL.
In the resected specimen, it was observed that the tumor was 30 × 21 mm in diameter, and pathological examination revealed a moderately differentiated tubular adenocarcinoma with subserosal invasion and three metastatic lymph nodes. The final pathological stage was pT3N2M0 stage IIIA according to the third edition of Japanese Classification of Gastric Carcinoma . The postoperative course was uneventful, and the patient was discharged at 14 days after surgery. Notably, the patient was administered adjuvant chemotherapy with oral anticancer agents. There is no evidence of recurrence at 6 months postoperatively.
The occurrence of advanced gastric cancer in patients with SIT is rare. As the intra-abdominal anatomy is complex for surgery in SIT cases, laparoscopic gastrectomy is a technically demanding procedure, especially for advanced gastric cancer cases. Therefore, using Medline and PubMed databases for case reports, we searched for literature published in the English language from 2000 to 2022 with the following keywords: “advanced gastric cancer”, “laparoscopic gastrectomy”, and “situs inversus totalis”. The characteristics of patients with SIT and advanced gastric cancer who underwent laparoscopic gastrectomy were found in four previous reports. These case reports are listed in Table 1 [3,4,5,6]. Three of the listed cases had vessel abnormalities. All of the previous reports showed clinical absence of lymph node metastases and D2 lymph node dissection. Our case had a longer operation time compared with previous reports; on the other hand, the patient had minimum blood loss, less than 10 mL. The postoperative course in each case was uneventful.
According to the latest Japanese gastric cancer treatment guidelines, laparoscopic gastrectomy for clinical stage I cancer has become a standard treatment in clinical trials [2, 9]. Moreover, D2 lymph node dissection is considered a standard procedure [10, 11]. Recent RCTs from Japan and Eastern Asia demonstrated the technical feasibility of laparoscopic gastrectomy with D2 lymph node dissection for advanced gastric cancer treatment [12,13,14]. In addition, as the efficacy of this procedure has been proven in these trials [15, 16], it could be a standard treatment.
In patients with SIT and advanced gastric cancer, there are several concerns regarding the safety of laparoscopic gastrectomy. First, anatomical variations, such as vessels and visceral organs, are known to make this procedure challenging. Therefore, an accurate understanding of surgical anatomy is necessary before surgery. Previous reports have shown that 3D CT angiography is a useful modality for confirming surgical anatomy [3,4,5]. In our case, 3D CT clearly demonstrated that the CHA directly originated from the SMA. Based on the preoperative information, we performed adequate D2 lymph node dissection of the metastatic lymph nodes, despite the vessel abnormality. In addition, malformation of the small intestine, which is often observed in patients with SIT, may influence the complexity of Roux-en-Y reconstruction. In this case, preoperative simulation using 3D CT helped us understand the mesentery of the small intestine loops.
Second, the possibility of varying the surgical procedures, such as trocar position, surgeon’s positioning and usage of energy device is a concern, although the oncological concept is not different even in an SIT case. The fact that our patient had clinically metastatic lymph nodes added to the technical difficulties. An accurate anatomical understanding is essential to secure a safe operative field. For example, the lower border of the pancreas, transverse mesocolon, right epiploic vessels, and duodenum are considered landmarks for lymph node dissection in the infrapyloric area. In the suprapancreatic area, the upper border of the pancreas and the outermost layer around the major vessels are the landmarks. Notably, the mirror image led to inconvenient maneuvers for the operator and assistants in this case; however, we frequently changed our position to secure the appropriate operation field and recognition of surgical landmarks. In addition, the usage of the dominant hand may often be the opposite of the usual manner. In our case, the non-dominant hand was used to hold the forceps or energy devices in some parts of the operation as planned. Despite the above measures, the operation time in this case was higher than that in the case without SIT. Frequently changing position of either operator or assistant to find anatomical landmarks and secure appropriate operation field during operation for SIT cases may need more time. Regarding reconstruction, the extracorporeal Roux-en-Y method was selected owing to tumor location and small size of the remnant stomach. Although there are possible reasons of the longer operation time, we should make efforts to reduce the operation time in the next SIT case based on sufficient review of this case.
Furthermore, the surgical team that will perform this operation seems to be an important consideration. In Japan, the endoscopic surgical skill qualification system (ESSQS) was established in 2004 to maintain laparoscopic technical skills and a standardized laparoscopic surgery process. Recent studies have shown that ESSQS-certified surgeons are more likely to deliver favorable outcomes after laparoscopic gastrectomy for gastric cancer [17, 18]. Therefore, it is preferable that ESSQS-certified surgeons participate in cases of advanced gastric cancer with SIT to perform the surgery safely. The operation was completed without any intra- or post-operative complications in our case.
Robotic gastrectomy has been introduced and is rapidly advancing in practice to overcome the range-of-motion limitation in laparoscopic gastrectomy for gastric cancer. Recent reports have demonstrated the technical advantages of robotic gastrectomy in patients with SIT [19, 20]. First, it is not necessary to change the position of surgeons during operation. Second, the surgeon can use the instrument with the non-dominant hand while having the same feeling as using the dominant hand. In contrast, the mirror image on abnormal surgical anatomy remains a concern. Notably, it is essential to select either laparoscopic or robotic surgery based on the understanding of the advantages and disadvantages of each modality.
This case report showed that LDG could be safely performed on a patient, even under complex conditions, such as advanced gastric cancer with lymph node metastasis with SIT and vascular anomalies.
Availability of data and materials
All data generated during this study are included in this article.
Situs inversus totalis
Randomized controlled trial
Laparoscopic distal gastrectomy
Common hepatic artery
Superior mesenteric artery
Left gastric artery
Proper hepatic artery
Spoon JM. Situs inversus totalis. Neonatal Netw. 2001;20:59–63. https://doi.org/10.1891/0730-08188.8.131.52.
Katai H, Mizusawa J, Katayama H, Morita S, Yamada T, Bando E, et al. Survival outcomes after laparoscopy-assisted distal gastrectomy versus open distal gastrectomy with nodal dissection for clinical stage IA or IB gastric cancer (JCOG0912): a multicentre, non-inferiority, phase 3 randomised controlled trial. Lancet Gastroenterol Hepatol. 2020;5:142–51. https://doi.org/10.1016/S2468-1253(19)30332-2.
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. https://doi.org/10.5230/jgc.2013.13.4.266.
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. https://doi.org/10.3748/wjg.v21.i35.10246.
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. 2018;11:39–42. https://doi.org/10.1111/ases.12404.
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. https://doi.org/10.21873/invivo.12331.
Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma—3rd English edition. Gastric Cancer. 2011;14:101–12. https://doi.org/10.1007/s10120-011-0041-5.
Tanigawa N, Lee SW, Kimura T, Mori T, Uyama I, Nomura E, et al. The endoscopic surgical skill qualification system for gastric surgery in Japan. Asian J Endosc Surg. 2011;4:112–5. https://doi.org/10.1111/j.1758-5910.2011.00082.x.
Katai H, Mizusawa J, Katayama H, Kunisaki C, Sakuramoto S, Inaki N, et al. Single-arm confirmatory trial of laparoscopy-assisted total or proximal gastrectomy with nodal dissection for clinical stage I gastric cancer: Japan Clinical Oncology Group study JCOG1401. Gastric Cancer. 2019;22:999–1008. https://doi.org/10.1007/s10120-019-00929-9.
Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2018, 5th ed. Gastric Cancer. 2021;24:1–21. https://doi.org/10.1007/s10120-020-01042-y.
Degiuli M, De Manzoni G, Di Leo A, D’Ugo D, Galasso E, Marrelli D, et al. Gastric cancer: current status of lymph node dissection. World J Gastroenterol. 2016;22:2875–93. https://doi.org/10.3748/wjg.v22.i10.2875.
Hu Y, Huang C, Sun Y, Su X, Cao H, Hu J, et al. Morbidity and mortality of laparoscopic versus open D2 distal gastrectomy for advanced gastric cancer: a randomized controlled trial. J Clin Oncol. 2016;34:1350–7. https://doi.org/10.1200/JCO.2015.63.7215.
Lee HJ, Hyung WJ, Yang HK, Han SU, Park YK, An JY, et al. Short-term outcomes of a multicenter randomized controlled trial comparing laparoscopic distal gastrectomy with D2 lymphadenectomy to open distal gastrectomy for locally advanced gastric cancer (KLASS-02-RCT). Ann Surg. 2019;270:983–91. https://doi.org/10.1097/SLA.0000000000003217.
Inaki N, Etoh T, Ohyama T, Uchiyama K, Katada N, Koeda K, et al. A multi-institutional, prospective, phase II feasibility study of laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for locally advanced gastric cancer (JLSSG0901). World J Surg. 2015;39:2734–41. https://doi.org/10.1007/s00268-015-3160-z.
Yu J, Huang C, Sun Y, Su X, Cao H, Hu J, et al. Effect of laparoscopic vs open distal gastrectomy on 3-year disease-free survival in patients with locally advanced gastric cancer: the CLASS-01 randomized clinical trial. JAMA. 2019;321:1983–92. https://doi.org/10.1001/jama.2019.5359.
Hyung WJ, Yang HK, Park YK, Lee HJ, An JY, Kim W, et al. Long-Term outcomes of laparoscopic distal gastrectomy for locally advanced gastric cancer: the KLASS-02-RCT randomized clinical trial. J Clin Oncol. 2020;38:3304–13. https://doi.org/10.1200/JCO.20.01210.
Akagi T, Endo H, Inomata M, Yamamoto H, Mori T, Kojima K, et al. Clinical impact of endoscopic surgical skill qualification system (ESSQS) by Japan Society for Endoscopic Surgery (JSES) for laparoscopic distal gastrectomy and low anterior resection based on the National Clinical Database (NCD) registry. Ann Gastroenterol Surg. 2020;4:721–34. https://doi.org/10.1002/ags3.12384.
Kikuchi S, Kagawa T, Kuroda S, Nishizaki M, Takata N, Kuwada K, et al. Accreditation as a qualified surgeon improves surgical outcomes in laparoscopic distal gastrectomy. Surg Today. 2021;51:1978–84. https://doi.org/10.1007/s00595-021-02309-2.
Aisu Y, Kadokawa Y, Kato S, Yasukawa D, Kimura Y, Hori T. Robot-assisted distal gastrectomy with lymph node dissection for gastric cancer in a patient with situs inversus partialis: a case report with video file. Surg Case Rep. 2018;4:16. https://doi.org/10.1186/s40792-018-0422-7.
Dai HB, Wang ZC, Feng XB, Wang G, Li WY, Hang CH, et al. Case report about a successful full robotic radical gastric cancer surgery with intracorporeal robot-sewn anastomosis in a patient with situs inversus totalis and a two-and-a-half-year follow-up study. World J Surg Oncol. 2018;16:41. https://doi.org/10.1186/s12957-018-1311-z.
We thank Dr. Shinichiro Empuku, Dr. Tomonori Akagi, and Dr. Tomotaka Shibata for their support.
This study was funded by the Japan Agency for Medical Research and Development (Grant Number JP19he2302003).
Ethics approval and consent to participate
This study was approved by the Institutional Review Board of Oita University Hospital, Oita, Japan.
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The patient in this study provided written informed consent authorizing the use and disclosure of protected health information.
The authors declare that they have no competing interests.
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Fujita, S., Etoh, T., Kono, Y. et al. Laparoscopic distal gastrectomy for advanced gastric cancer with situs inversus totalis: a case report. surg case rep 8, 182 (2022). https://doi.org/10.1186/s40792-022-01532-4
- Situs inversus totalis
- Advanced gastric cancer
- Laparoscopic gastrectomy