Robot-assisted low anterior resection for situs inversus totalis: A novel technical approach for an uncommon condition

INTRODUCTION: Situs inversus totalis (SIT) is an uncommon condition, with an incidence of 1 in 10,000. Surgery for SIT patients is more difficult because of the uncommon anatomy. Experience in laparoscopic surgery for patients with SIT is very limited. Only a few cases of laparoscopic colorectal resections have been reported in the literature. We present the first robot-assisted low anterior resection for rectal cancer in a patient with SIT. PATIENT: A 70-year-old woman with SIT who presented with rectal bleeding underwent a colonoscopy and barium enema. This workup revealed a rectal cancer 10 cm from the anal verge. The magnetic resonance imaging scan revealed a T3/4 tumor in the rectum with perirectal lymph node involvement, whereas the computed tomography positron emission tomography scan did not reveal any distal metastasis. She underwent neoadjuvant chemoradiotherapy 6 weeks before surgery. Postoperatively, she made an uneventful recovery and was discharged on day 6. SURGICAL TECHNIQUE: After laparoscopic examination and displacement of the small bowel, 4 robot trocars were inserted into 4 quadrants of the abdomen. A fifth port was inserted and used by the assistant. The robot cart was docked from the right side with arms 1, 2, and 3 in the right upper quadrant (Cadiere grasper), left lower quadrant (bipolar Maryland grasper), and left upper quadrant (monopolar scissors), respectively, for colonic mobilization without splenic flexure takedown. For pelvic dissection, arms 1 and 3 were moved to the right upper quadrant and right lower quadrant, respectively. After adequate pelvic dissection, the robot cart was undocked, and a laparoscopic articulating linear stapler was used to transect the rectum from the left lower quadrant port. Bowel continuity was restored with a circular stapler. A loop ileostomy was created through the extraction site in the right lower quadrant. CONCLUSIONS: Robot-assisted low anterior resection for SIT patients can be performed safely and confers the benefits of laparoscopic low anterior resection with additional advantages unique to the da Vinci system.