CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 5 (2014) 1207–1209 Contents lists available at ScienceDirect International Journal of Surgery Case Reports journa l h omepage: www.casereports.com Laparoscopic Nissen Rossetti fundoplication in situs inversus totalis—A blessing in disguise Kaundinya Kiran Bharatam a,∗ , Manuneethi Maran b , P.K. Siva Raja c a Consultant General, Laparoscopic and Endoscopic Surgeon, Mehta Hospitals, Chennai, India b Mehta Hospital, Chennai, India c Sri Ramachandra Medical College, Chennai, India a r t i c l e i n f o Article history: Received 4 September 2014 Received in revised form 12 November 2014 Accepted 12 November 2014 Available online 18 November 2014 Keywords: Laparoscopy Fundoplication Situs inversus totalis Gas bloating syndrome Less intra operative times Less blood loss a b s t r a c t INTRODUCTION: Laparoscopic Nissen fundoplication and Nissen Rossetti fundoplication represent two different surgical approaches for treating hiatus hernia. We report a Laparoscopic Nissen Rossetti fun- doplication (LNRF) for gastro esophageal reflux disease (GERD) in a patient with situs inversus totalis (SIT). PRESENTATION OF CASE: : A 38-year-old man with SIT was diagnosed with sliding hiatus hernia. We performed Laparoscopic Nissen Rossetti procedure for this patient. The patient was discharged on first postoperative day after he tolerated oral liquids. DISCUSSION: SIT is a rare anomaly presenting in 1–2 per 10,000 individuals. As this rare anomaly (SIT) led preoperative anticipation of respiratory and blood loss complications the above procedure was chosen. Less operating time, less calculated blood loss and improvement of symptoms with no associated gas bloating syndrome was noted especially with SIT. CONCLUSION: We recommend relook into the Laparoscopic Nissen Rossetti fundoplication as an effective procedure in GERD especially with rare anomalies like SIT. © 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). 1. Introduction Laparoscopic Nissen fundoplication and Nissen Rossetti fundo- plication represent two different surgical approaches for treating hiatus hernia. 1,2 Studies comparing these two procedures high- lighted the decreased intra operative times and the decreased incidence of gas bloating syndromes in the Nissen Rossetti fundo- plication procedure. The incidence of postoperative dysphagia was almost similar to its counterpart. The functional outcomes of both the procedures for the relief of GERD symptoms were similar. 1,2 SIT with mirror – image dextrocardia was described first in 1643 by Severinus. 9,10 It is thought to be occurring in around 1–2 individ- uals per 10,000 and with equal frequency in males and females. 3,4,12 It is characterized by transposition of abdominal viscera, and with dextrocardia and it is referred to as situs inversus totalis (SIT). The anomaly may coexist with congenital cardiac defects in 10% and with Kartagener’s syndrome or primary ciliary dyskinesia (PCD), which refers to ciliary dysfunction in 20%. 11,12 The patients may have normal longevity as compared to the normal population. ∗ Corresponding author at: Flat-14, E Block, Sterling Ganges, 214/32, Next to Nilgiris Superstore, Katupakkam, Chennai 56, India. Tel.: +91 9962631244. E-mail address: [email protected] (K.K. Bharatam). Ultrasonography may help in the diagnosis of the condition in itself with the possible associated anomalies. 14 Documenting situs inversus in an individual is important to modify the surgical technique in order to prevent any inadver- tent clinical or surgical mishap. This is especially because of its possible associations with primary ciliary dyskinesia and splenic malformations. 3,4 We present what is possibly the first reported case of laparo- scopic Nissen–Rossetti fundoplication in a patient with SIT from India. 2. Case report A 38-year-old man with SIT was diagnosed with a sliding hiatal hernia. Nissen Rossetti fundoplication was done in modified litho- tomy position. The ports were placed in a configuration that was the mirror image of our usual fundoplication procedure. 8 The pro- cedure was carried out in the standard fashion with intrathoracic dissection of the esophagus and the cardia of the stomach, which was brought down below the esophageal hiatus with adequate length and without tension. The short gastric vessels were not divided to mobilize the gastric fundus. Closure of the crura and a fundic wrap was done with 2/0 polyglactin 910 (Vicryl, Ethicon Inc., Johnson and Johnson) sutures tied intra-corporeally. The total http://dx.doi.org/10.1016/j.ijscr.2014.11.046 2210-2612/© 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
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CASE REPORT – OPEN ACCESSInternational Journal of Surgery Case Reports 5 (2014) 1207–1209
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports
journa l h omepage: www.caserepor ts .com
aparoscopic Nissen Rossetti fundoplication in situs inversusotalis—A blessing in disguise
aundinya Kiran Bharatama,∗, Manuneethi Maranb, P.K. Siva Rajac
Consultant General, Laparoscopic and Endoscopic Surgeon, Mehta Hospitals, Chennai, IndiaMehta Hospital, Chennai, IndiaSri Ramachandra Medical College, Chennai, India
r t i c l e i n f o
rticle history:eceived 4 September 2014eceived in revised form2 November 2014ccepted 12 November 2014vailable online 18 November 2014
eywords:aparoscopy
a b s t r a c t
INTRODUCTION: Laparoscopic Nissen fundoplication and Nissen Rossetti fundoplication represent twodifferent surgical approaches for treating hiatus hernia. We report a Laparoscopic Nissen Rossetti fun-doplication (LNRF) for gastro esophageal reflux disease (GERD) in a patient with situs inversus totalis(SIT).PRESENTATION OF CASE: : A 38-year-old man with SIT was diagnosed with sliding hiatus hernia. Weperformed Laparoscopic Nissen Rossetti procedure for this patient. The patient was discharged on firstpostoperative day after he tolerated oral liquids.DISCUSSION: SIT is a rare anomaly presenting in 1–2 per 10,000 individuals. As this rare anomaly (SIT) led
undoplicationitus inversus totalisas bloating syndromeess intra operative timesess blood loss
preoperative anticipation of respiratory and blood loss complications the above procedure was chosen.Less operating time, less calculated blood loss and improvement of symptoms with no associated gasbloating syndrome was noted especially with SIT.CONCLUSION: We recommend relook into the Laparoscopic Nissen Rossetti fundoplication as an effectiveprocedure in GERD especially with rare anomalies like SIT.
© 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an openhe CC
access article under t. Introduction
Laparoscopic Nissen fundoplication and Nissen Rossetti fundo-lication represent two different surgical approaches for treatingiatus hernia.1,2 Studies comparing these two procedures high-
ighted the decreased intra operative times and the decreasedncidence of gas bloating syndromes in the Nissen Rossetti fundo-lication procedure. The incidence of postoperative dysphagia waslmost similar to its counterpart. The functional outcomes of bothhe procedures for the relief of GERD symptoms were similar.1,2
SIT with mirror – image dextrocardia was described first in 1643y Severinus.9,10 It is thought to be occurring in around 1–2 individ-als per 10,000 and with equal frequency in males and females.3,4,12
t is characterized by transposition of abdominal viscera, and withextrocardia and it is referred to as situs inversus totalis (SIT). Thenomaly may coexist with congenital cardiac defects in 10% andith Kartagener’s syndrome or primary ciliary dyskinesia (PCD),
hich refers to ciliary dysfunction in 20%.11,12 The patients mayave normal longevity as compared to the normal population.∗ Corresponding author at: Flat-14, E Block, Sterling Ganges, 214/32, Next toilgiris Superstore, Katupakkam, Chennai 56, India. Tel.: +91 9962631244.
E-mail address: [email protected] (K.K. Bharatam).
ttp://dx.doi.org/10.1016/j.ijscr.2014.11.046210-2612/© 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Ahttp://creativecommons.org/licenses/by-nc-nd/3.0/).
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
Ultrasonography may help in the diagnosis of the condition in itselfwith the possible associated anomalies.14
Documenting situs inversus in an individual is important tomodify the surgical technique in order to prevent any inadver-tent clinical or surgical mishap. This is especially because of itspossible associations with primary ciliary dyskinesia and splenicmalformations.3,4
We present what is possibly the first reported case of laparo-scopic Nissen–Rossetti fundoplication in a patient with SIT fromIndia.
2. Case report
A 38-year-old man with SIT was diagnosed with a sliding hiatalhernia. Nissen Rossetti fundoplication was done in modified litho-tomy position. The ports were placed in a configuration that wasthe mirror image of our usual fundoplication procedure.8 The pro-cedure was carried out in the standard fashion with intrathoracicdissection of the esophagus and the cardia of the stomach, whichwas brought down below the esophageal hiatus with adequate
length and without tension. The short gastric vessels were notdivided to mobilize the gastric fundus. Closure of the crura anda fundic wrap was done with 2/0 polyglactin 910 (Vicryl, EthiconInc., Johnson and Johnson) sutures tied intra-corporeally. The totalssociates Ltd. This is an open access article under the CC BY-NC-ND license
CASE REPORT – OPEN ACCESS1208 K.K. Bharatam et al. / International Journal of Surgery Case Reports 5 (2014) 1207–1209
Fig. 1. Fundoplication in situs inversus totalis.
Fig. 2. Fundoplication in situs inversus totalis.
Fig. 3. Dextrocardia depicted in the patient with situs inversus totalis.
Fig. 4. Patient with doctor and the depiction of ports placed in the patient forlaparoscopic fundoplication in situs inversus totalis.
operative time was 90 min. The patient was discharged on firstpostoperative day after he tolerated oral liquids (Figs. 1–4).
3. Discussion
The challenges expected in this anomaly were anticipatingsplenic malformations with unexpected blood loss during the divi-sion of short gastric vessels.9–14 Decreasing the intra operative timewas prime due to possible primary ciliary dyskinesia causing respi-ratory complications in the patient who had a 10-year history ofsmoking.12,13
Though no complications have been encountered till date ineither procedure at our center, still this rare anomaly (SIT) led pre-operative anticipation of respiratory and blood loss complications.Thus we chose to perform Nissen Rosette fundoplication for thepatient.
4. Conclusion
Laparoscopic Nissen Rossetti fundoplication (LNRF) can be per-formed in SIT safely with the benefit of decreased postoperativetimes and avoidance of unexpected blood loss. Postoperative dys-phagia is relatively less in the former procedure and this isexplained by studies. Safe surgery for GERD is of utmost importanceto overcome the technical and ergonomic difficulties especially inSIT.
Conflict of interest
None declared.
Funding
None.
Ethical approval
Written informed consent was obtained from the patient for
publication of this case report and accompanying images. A copyof the written consent is available for review by the Editor-in-Chiefof this journal on request.
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CASE REPORTK.K. Bharatam et al. / International Journ
uthor contributions
Dr Kaundinya Kiran Bharatam: Main author and primary con-ultant involved in the treatment of this patient and procedure.
as the main surgeon in the surgical procedure mentioned. Dranuneethi Maran: Co-author and secondary consultant involved
n the treatment of this patient and procedure. Was the secondurgeon in the surgical procedure mentioned. Dr P.K. Siva Raja:o-author and assistant consultant involved in the treatment ofhis patient and procedure. Was the second surgeon in the surgicalrocedure mentioned.
eferences
1. Chrysos E, Tzortzinis A, Tsiaoussis J, Athanasakis H, Vasssilakis, Xynos E.Prospective randomized trial comparing Nissen to Nissen-Rossetti techniquefor laparoscopic fundoplication. Am J Surg 2001;182(3):215–21.
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1
pen Accesshis article is published Open Access at sciencedirect.com. It is distribermits unrestricted non commercial use, distribution, and reproductredited.
PEN ACCESSrgery Case Reports 5 (2014) 1207–1209 1209
2. Leggett PL, Bissell CD, Churchman-Winn R, Ahn C. A comparison of laparoscopicNissen Fundoplication and Rossetti’s modification in 239 patients. Surg Endosc2000;14(5):473–7.
3. Applegate KE, Goske MJ, Pierce G, Murphy D. Situs revisited: imaging of hetero-taxy syndrome. Radiographics 1999;19:837–52 [PubMed].
4. Sharma S, Chaitanya KK, Suseelamma D. Situs inversus totalis (dextroversion) –an anatomical study. Anat Physiol 2012, 2:5.
8. Khandelwal RG, Karthikeyan S, Balachander TG, Reddy PK. Laparoscopic Nissenfundoplication in situs inversus totalis: technical and ergonomic issues. J MinimAccess Surg 2010;6(4):116–8.
9. Brown JW. Congenital heart disease. London: Staples Press, Ltd; 1950.0. Fabricus, cited by Cleveland M. Situs inversus viscerum: anatomic study. Arch
Surg 1926;13:343.1. Shogan 1 PJ, Folio L. Situs inversus totalis. Mil Med 2011;176(7):840–3.2. Roongruangchai 1 J, Narongsak W, Plakornkul V, Viravud Y, Sripaoraya K, Roon-
gruangchai K. Situs inversus totalis and ultrastructure of respiratory cilia: reportof a cadaveric case. J Med Assoc Thai 2012;95(1):132–8.
3. Kartageiner NI, Stucki P. Bronchiectasis with situs inversus. Arch Pediatr1962;79:193.
4. Douglas P, Grey MD, Denton A, Cooley MD. Dextrocardia with situs inversustotalis: cardiovascular surgery in three patients with concomitant coronaryartery disease. Cardiovasc Dis 1981;8(4):527–30.
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