Laparoscopic Distal Gastrectomy Using Multimodal Visualization in a Patient with Situs Inversus Totalis and a...

Situs inversus totalis (SIT) is a rare congenital condition characterized by the complete mirror-image transposition of the thoracic and abdominal organs. Although arterial anomalies in SIT have been reported, venous anomalies, particularly those involving the portal venous system, are extremely rare and may increase the technical difficulty of minimally invasive surgery. We report a case of laparoscopic distal gastrectomy in a patient with SIT accompanied by a duplicated portal vein (DPV).

A 75-year-old woman with SIT presented with epigastric discomfort and was diagnosed with gastric cancer and multiple gallstones. Preoperative 3D-CT angiography revealed several vascular anomalies, including a DPV. Laparoscopic distal gastrectomy with D1+ lymphadenectomy and concomitant cholecystectomy was successfully performed using 3 surgical strategies. Preoperative 3D-CT evaluation enabled accurate identification of the vascular anatomy, and intraoperative multimodal visualization using 3 monitors facilitated safe orientation in the mirror-image operative field. Continuous communication between the surgeon and assistant further prevented anatomical misinterpretation. The operative time was 307 min, and blood loss was 50 mL. The postoperative course was uneventful, and the patient was discharged on POD 12. Histopathological examination revealed pT1b, pN0, cM0, and Stage IA gastric adenocarcinoma.

Careful attention should be paid not only to mirror-image anatomy but also to vascular anomalies, particularly those of the venous system, in patients with SIT. Detailed preoperative and intraoperative assessments using multimodal visualization in conventional laparoscopic surgery may provide essential anatomical orientation, facilitating safe navigation, dissection, and precise intracorporeal reconstruction.