PMC10034810_01
Pre-operative imaging of situs inversus totalis patient. Images of pre-operative chest X-ray film (a), gastrointestinal barium fluoroscopy (b) and abdominal computed tomography (c) shows situs inversus totalis and irregular thickening of gastric wall (red arrow)
JMAS-19-147-g001.jpg
PMC10034810_01_JMAS-19-147-g001.jpg
jmas_311_21-f001
Chest radiography indicated mirror dextrocardia [Figure 1a]. Gastrointestinal barium fluoroscopy [Figure 1b] revealed the following: (1) SIT and (2) potential space-occupying lesion in the gastric antrum. Chest + whole abdomen contrast-enhanced computed tomography (CT) [Figure 1c] showed the following: (1) SIT; (2) irregularly thickened gastric wall of the antrum, with the possibility of gastric antral carcinoma and (3) slightly larger lymph nodes (LNs) in the hepatogastric space.
Gastrointestinal barium fluoroscopy after digestive tract reconstruction on day 3
JMAS-19-147-g002.jpg
PMC10034810_01_JMAS-19-147-g002.jpg
jmas_311_21-f002
On day 3, the patient underwent gastrointestinal barium fluoroscopy after digestive tract reconstruction [Figure 2] and was discharged on day 8.
Based on membranous anatomy, laparoscopy-assisted radical distal gastrectomy. Abdominal anatomic structures viewed by laparoscopy during surgery (a). An intraoperative image showing the procedure of dissecting the lower pyloric region (b). Separating the left area of the celiac trunk (c). Separating the right area of the celiac trunk (d) RGEV - right gastroepiploic vein, RGEA - right gastroepiploic artery, GDA- gastroduodenal artery, RGV - right gastric vein, CHA - common hepatic artery, LGA - left gastric artery
JMAS-19-147-g003.jpg
PMC10034810_01_JMAS-19-147-g003.jpg
jmas_311_21-f003
Intraoperative laparoscopy revealed the following: the liver and gall bladder were located in the left upper abdomen, the spleen was located in the upper right abdomen, the greater curvature of the stomach fundus was located on the right side and the pylorus and duodenum were located on the left side [Figure 3a]. Based on membranous anatomy, 3D laparoscopy-assisted radical gastrectomy by the 'enjoyable space' approach was employed to achieve complete tumour resection + D2 LN dissection. (1) Using the 'pick up and separate method' to dissect the lower pyloric region [Figure 3b], the surgeon used blunt separations to enter the gastrocolic fusional fascial space and then dissected the anterior fascia of the head of pancreas along the anterior pancreatic head and separated the right gastroepiploic vein. From the lower edge to the upper edge of the pancreatic neck, the root of the right gastroepiploic artery was disconnected to achieve LN dissection in the lower pyloric region. (2) Using the 'Tent method' to separate the left area of the celiac trunk [Figure 3c], the surgeon dissected the anterior pancreatic fascia and the mesangial lobe of the hepatoduodenal ligament to reach the common bile duct leftward. The coronary vein was exposed and disconnected. (3) Using the 'enjoyable space separation method' to separate the right area of the celiac trunk [Figure 3d], the surgeon made an incision at the junction of the left gastric artery and splenic artery, entered into the fusional fascial space between the gastric dorsal mesangium and retroperitoneum (i.e., the 'enjoyable space').