LAPAROSCOPIC LOW ANTERIOR RESECTION FOR DIVERTICULAR DISEASE ON A PATIENT WITH SITUS INVERSUS TOTALIS

Lucia Collar Yagas, MD¹, Nicolas M Cordoba, MD², Jan P Kamiski, MD, MBA¹, Joaquin J Estrada, MD, FACS, FACRS¹. ¹Advocate Illinois Masonic Medical Center, ²Private Practice

Situs inversus totalis (SIT) is a rare condition with an approximate incidence of 1:10,000 live births, in which the position of the thoracic and abdominal organs is inverted presenting as a mirror image of the normal anatomic layout called situs solitus. Colonic diverticulosis is, on the other hand, a common clinical condition with a prevalence that increases with age, being 1 to 2 % in patients under the age of 30 and over 40% after age 60. Approximately a quarter of such patients will develop acute diverticulitis.

We present a case of SIT and recent history of complicated acute diverticulitis, and our experience performing a laparoscopic low anterior resection. To our knowledge, there have been no similar cases previously reported in the literature.

A 29-year-old male with SIT and polysplenia presented after an episode of acute sigmoid diverticulitis complicated by an intra-abdominal abscess. He had a previous episode of uncomplicated diverticulitis.

Due to the recurrent episodes of diverticulitis, the complicated course of the last one, and the patient's abnormal topography, a sigmoid colon resection was recommended, as well as an appendectomy in view of the atypical location of the appendix.

A laparoscopic low anterior resection (LAR) with primary anastomosis and an appendectomy were performed. Special consideration regarding port placement and position of the surgeon and assistant were taken. The operator was situated at the left side of the patient and the assistant at the right, which is opposite to a conventional laparoscopic LAR. Ports were placed in a mirrored fashion to their regular placement. The surgeon used his left hand as the main working hand for most of the procedure. Extra care was taken due to the presence of multiple accessory spleens. The surgery was completed safely with an operating time of 180 min and minimal blood loss.

Conclusion: In a patient with SIT and history of diverticulitis, surgery should be indicated to avoid future problems such as misdiagnosis, delay in treatment and the possible complications that these might bring. Similarly, a prophylactic appendectomy should be performed at the time of a laparoscopy for any other indication.

SIT represents a technical challenge for the surgeon. A laparoscopic approach is feasible and safe in the hands of an experienced surgeon. Understanding the aberrant anatomy and being able to adjust technical aspects of the surgery to this condition are key elements for the success of a laparoscopic LAR.