Situs inversus totalis (SIT) is characterized by a complete mirror inversion of the anatomical positions of the thoracic and abdominal organs. The incidence is reported to be between 1 in 8000 and 1 in 25000.[1,2] SIT can present either as a component of other syndromes or as an isolated, asymptomatic condition with the same physiological function as normal people.[3] Notably, congenital anatomical abnormalities may lead to a diagnosis, and surgical treatment encounters difficulties once SIT patients develop diseases.[4]
Pancreatic cancer (PC) is one of the worst digestive malignancies with insidious clinical manifestations, rapid progression, and difficulty in early diagnosis. The overall 5-year survival rate of PC is only about 10%.[5] Pancreaticoduodenectomy (PD) is the “gold standard” for radical resection of pancreatic head and neck cancer. Open pancreaticoduodenectomy (OPD) or laparoscopic pancreaticoduodenectomy (LPD) in PC patients with SIT has been reported in several pieces of literature.[6–8] However, robot-assisted pancreaticoduodenectomy (RPD) for PC has not been reported. We report a patient with PC and SIT who underwent RPD, aiming to provide the experience for the surgical treatment of PC complicated with SIT.
Case report
A 57-year-old male patient presented to our hospital in June 2022 with epigastric pain, nausea, and weight loss over 1 month. An abdominal ultrasound revealed a pancreatic mass. Serum CA19-9 was 41.09 U/mL. Computed tomography (CT) showed: 1) transposition of the heart and abdominal organs; 2) a 3.4 cm × 2.5 cm mass at the head and neck junction of the pancreas, not clearly demarcated from the surrounding tissue; 3) dilated distal main pancreatic duct; 4) multiple small lymph nodes around the lesion; 5) close relationship between the lesion and main trunk of the superior mesenteric vein (SMV) (Fig. 1A–C). Then, an ultrasound-guided needle biopsy was performed, and pathology revealed a pancreatic ductal adenocarcinoma.
;)
Figure 1.: Imaging characteristics (A–C), operation hole layout (D), and intraoperative photographs (E–J). R1 = robot arm 1, R2 = robot arm 2, R3 = robot arm 3, R4 = robot arm 4, PV = portal vein, SMA = superior mesenteric artery, SMV = superior mesenteric vein.
About history, the patient underwent liver repair surgery for a traumatic rupture of the liver 20 years ago. In a traffic accident, he fractured his left femur and right knee joint 2 years ago. In addition, the patient had 30 years of smoking and drinking.
After preoperative preparation, RPD (da Vinci Xi) for the patient was performed. The patient was placed in a supine position with 2 legs apart. The trocar layout can be seen in Figure 1D. After the peritoneal adhesion was treated, the gastrocolic ligament was dissected, and the right gastroepiploic l vessels were severed. The tumor can be seen at the head and neck of the pancreas (Fig. 1E). After that, the lesser omentum was dissected, and the “left gastric vessels” (equivalent to the right gastric vessels in a normal person) were dissociated and severed. Then, the hepatic flexure of the colon was dissociated to expose the descending part of the duodenum. The lateral mesoduodenum was dissected, the head of the pancreas and the posterior part of the duodenum were dissociated, and the horizontal part of the duodenum was dissected to the right side of Treitz’s ligament (Fig. 1F). No enlarged lymph nodes were found paraaortic. The jejunum was dissected 5 cm distal to the Treitz’s ligament using the linear cutter (Fig. 1G). The gallbladder was removed retrograde (Fig. 1H). The pancreatic capsule was opened, the upper margin of the pancreas was separated, the hepatic artery was exposed, the gastroduodenal artery (GDA) was exposed and severed, and the No. 8 lymph node was dissected. After the distal stomach was dissociated, the body of the stomach was cut using a linear cutter at a distance of 5 cm from the pylorus. The head of the pancreas and duodenum were pulled to the upper right, the root of the superior mesenteric artery (SMA) was found and carefully dissociated, and the branches of blood vessels between the SMA and the head of the pancreas were severed. The common bile duct was exposed, the No. 12 lymph node was dissected, and the common hepatic duct was severed at the level of the entrance of the cystic duct. The veins between SMV-portal vein (PV) and the head of the pancreas were severed (Fig. 1I). The distal and proximal parts of SMV-PV were pre-blocked because the tumor and SMV-PV severely adhered. After the tumor and vein were separated, the pancreaticoduodenal specimen was removed and sent for routine pathological examination (Fig. 2). The digestive tract was reconstructed by the Roux-en-Y method. Pancreaticojejunostomy was performed using 4-0 Proline and 5-0 PDS with continuous sutures. Cholangiojejunostomy was performed by using 5-0 PDS with continuous sutures. Drainage tubes were placed behind the cholangiojejunostomy and pancreaticojejunostomy, respectively. The operation was completed after irrigation and exploration of the abdominal cavity (Fig. 1J) About 700 mL of blood was lost during the operation. A total of 2U red blood cells and 400 mL fresh frozen plasma were transfused.
Figure 2.: The photo of the surgical specimen.
After the operation, the patient recovered well without complications and was discharged 10 days after surgery. The pathological outcomes reported a pancreatic ductal adenocarcinoma with peripancreatic lymph node metastasis (2/11).
The patient was followed up 5 months after surgery, and the quality of life was well without tumor recurrence or metastasis.
Discussion
The da Vinci robot can provide the operator with 10-fold magnified, 3-dimensional, and high-definition images. Besides, the mechanical arms are flexible and controllable, the movement can be scaled optionally, and it can eliminate the shaking of the hands of the operator. These incomparable advantages of traditional surgery have made robot-assisted surgery widely accepted. Moreover, lots of research showed that RPD was superior to OPD in terms of the R0 resection rate, the rate of infection at the wound site, the rate of reoperation, the postoperative length of stay, the rate of blood transfusions required during operation, and the rate of clinical postoperative pancreatic fistula.[9] Practice suggests that SIT is not contraindicated for RPD but makes the operation challenging. To adapt the inversion of the anatomical positions of the thoracic and abdominal organs, we placed the assistant port on the patient’s right mid-abdomen. In general, the operation of this patient was relatively smooth, but it is worth noting that the operation took 12 hours and the blood loss was about 700 mL, which was far more than the previous data of our team and the reports of existing literature about normal RPD.[9,10] There are several reasons for the difference in blood loss. First, the patient had previously undergone surgery for liver injury, and the abdominal adhesion was very severe. In addition, because of the abnormal anatomy made the operation more difficult, and some blood vessels were accidentally injured during the operation. Finally, the lengthening of the operation also increased the chance of bleeding. It is suggested that the patient be examined by 3-dimensional angiography and carefully read the patient’s imaging data before the operation to conceive the patient’s anatomical structure in advance. Moreover, it is advisable to convert to open laparotomy if necessary. Shortly, the robot can do the job, but it should be chosen carefully.
Acknowledgments
None.
Author contributions
JZ outlined, wrote, and drafted the manuscript. All authors critically revised the manuscript and approved the final version of the manuscript.
Financial support
This study was supported by CAMS Innovation Fund for Medical Sciences (CIFMS) (2021-I2M-1-002 & 2022-I2M-C&T-B-030); National High-Level Hospital Clinical Research Funding (2022-PUMCH-D-001 & 2022-PUMCH-B-004); National Multidisciplinary Cooperative Diagnosis and Treatment Capacity Building Project for Major Diseases.
Conflicts of interests
The authors declare no conflicts of interest.
Ethics approval
This case report represents a fully anonymized retrospective presentation. Therefore, the need for ethical approval was waived according to the regulation of the Ethics Committee of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College.
References
[1]. Gentile BA, Tighe DA.
Situs inversus totalis. N Engl J Med. 2019;380:e45e45.
[2]. Eitler K, Bibok A, Telkes G.
Situs inversus totalis: a clinical review. Int J Gen Med. 2022;15:2437–2449.
[3]. Levin M, Mercola M. The compulsion of chirality: toward an understanding of left-right asymmetry. Genes Dev. 1998;12:763–769.
[4]. Abbey E, Yang F, Qi L, et al.
Situs inversus totalis patients with gastric cancer: Robotic surgery the standard of treatment?-A case report. Int J Surg Case Rep. 2021;81:105818.
[5]. Siegel RL, Miller KD, Fuchs HE, et al. Cancer statistics, 2022. CA Cancer J Clin. 2022;72:7–33.
[6]. Chen C, Yi X, He Y, et al. Pancreatic head cancer involving variant common hepatic artery with
situs inversus totalis. ANZ J Surg. 2018;88:506–508.
[7]. Hussan MA, Yang Z, Dong X, et al. A laparoscopic pancreaticoduodenectomy for pancreatic adenocarcinoma in a patient with
situs inversus totalis. J Surg Case Rep. 2021;2021:rjab316.
[8]. Nagai K, Masui T, Kyogoku T, et al. Pancreatoduodenectomy with portal vein resection for pancreatic body cancer in a patient with
situs inversus totalis. Surg Oncol. 2022;43:101815.
[9]. Zhang W, Huang Z, Zhang J, et al. Safety and efficacy of robot-assisted versus open pancreaticoduodenectomy: a meta-analysis of multiple worldwide centers. Updates Surg. 2021;73:893–907.
[10]. Podda M, Gerardi C, Di Saverio S, et al. Robotic-assisted versus open pancreaticoduodenectomy for patients with benign and malignant periampullary disease: a systematic review and meta-analysis of short-term outcomes. Surg Endosc. 2020;34:2390–2409.
