A 63-year-old woman with partial Situs Viscerum Inversus (without dextrocardia) was diagnosed with giant sliding hiatus hernia and cholelithiasis. The symptoms were typical: heartburn, chest pain, burping and atypical respiratory symptoms as coughing and asthma. The preoperative evaluations was: gastrointestinal endoscopy (EGD), a barium swallow radiography, an intraluminal 24-H pH measurement and oesophageal manometry, abdominal ultrasound, chest and abdominal CT scan with contrast. The diagnosis of Situs Viscerum Inversus was on CT scan exam, and previously unknown. Anatomical variation has to be identified in the preoperative study to avoid intraoperative risks of iatrogenic injures during dissection and exposure of the anatomical structures.
A robot-assisted reduction of hiatal hernia in abdomen and Toupet fundoplication was performed, a Bio A mesh was placed as hiatoplasty reinforcement and gastropexy (to reduce the post-operative recurrence risk); the cholecystectomy was performed as well as the patient was affected by cholelithiasis. The patient was discharged on third postoperative day after X-ray check and he tolerated a solid food. The operation technique in SVI is quite specular to the conventional technique for robot-assisted fundoplication. The patient was placed in French position, with the surgeon standing between the patient's legs and robotic cart from the head/right shoulder. We used a 4-arms cart with the 4th arm from the left side (Fig. 1).
Carbon dioxide pneumoperitoneum was established using Veress' needle technique; a 12-mm incision in the right abdominal quadrant area over-umbilical line was made to insert the trocar for the camera; the ports were placed in a configuration that was roughly the mirror image of our usual fundoplication procedure. The first 12 mm port for the camera was inserted into the abdominal cavity in right ipocondrium, about 2 cm above umbilical line and four more trocars were inserted. After the internal organs of abdominal cavity examination we proceeded with the insertion of three more trocars under direct view. Trocars were placed in epigastric region, left hypocondrium and left lumbar region. The other robotic trocar and auxiliary AirSeal trocar placed.
Cholecystectomy was first performed. The right hepatic lobe lifted to expose the hiatus. The procedure was carried out in the standard fashion with trans-hiatal dissection of the oesophagus for about 6 cm distally. Reduction of the stomach into the abdomen and the right and left crura exposed, a para-hernia lipoma removed and oesophagus encircled using the articulated tips of robotic instruments and distal oesophagus prepared for about 6-8 cm into the mediastinum, removing the hernia sac. The right side of stomach dissected, no typical short gastric vessels were found, as the spleen was represented by two fetal presentation with a vascular supply from the kidney vessels (Fig. 2).
The left pillar dissected from the cava, the hiatoplasty performed using three stitches with pledgets and a Bio A mesh placed and sutured above the crura plane. Closure of the crura and a posterior partial fundic wrap (Toupet technique) was done with 3/0 Prolene (Prolene, Ethicon Inc., Johnson and Johnson) stitches tied intra-corporeally with hand made pledgets, using pieces of BioA prothesis.
Finally two trans parietal 0-Vycril stitches for the gastropexy between antrum and abdominal wall. The gallbladder was removed with an Endo-bag through the 10-mm operating port; and a drain placed near the hiatal area. The total operative time was 190 min. The patient was discharged on third postoperative day after a contrast upper GI X-ray exam and an oral semi-solid diet.
The operation time (cholecystectomy and fundoplication) was 190 min with no intraoperative complications. The postoperative course was uneventful, and the patient was discharged on postoperative day 3.