Mirror Image Hepatectomy in a Patient with Situs Inversus Totalis

Fukuoka Acta Med.
430
104(11):430―434,2013
Mirror Image Hepatectomy in a Patient with Situs Inversus Totalis
Hideaki UCHIYAMA1), Ken SHIRABE2), Tomoharu YOSHIZUMI2), Toru IKEGAMI2), Yuji SOEJIMA2),
Tetsuo IKEDA2), Hirofumi KAWANAKA2), Yo-ichi YAMASHITA2), Masaru MORITA2), Eiji OKI2),
Koushi MIMORI3), Keishi SUGIMACHI3), Hiroshi SAEKI2), Masayuki WATANABE4),
Kenji TAKENAKA1) and Yoshihiko MAEHARA2)
1)
Department of Surgery, Fukuoka City Hospital
Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University
3)
Department of Surgery, Kyushu University Beppu Hospital
4)
Department of Gastroenterological Surgery, Graduate School of Life Sciences,
Kumamoto University
2)
Abstract
Background : Hepatectomy in a patient with situs inversus patient is technically challenging because of
its complete mirror image anatomy, especially for a tumor located deep in the liver. Incorrectly
identifying intrahepatic vessels and biliary system would lead to serious complications. We
experienced a hepatectomy for a tumor in a patient with situs inversus totalis with referring to
computer-generated mirror images.
Methods : A 66-year-old female patient with situs inversus totalis was diagnosed with hepatocellular
carcinoma, 5 cm in diameter, centrally located just above the hepatic hilum compressing the right and
left hepatic duct. The liver infected with hepatitis C was cirrhotic with a moderate amount of ascites.
We preoperatively created several diagrams of the mirror image anatomy and made plans for how to
resect this tumor, presupposing the patient had an ordinary anatomy. The tumor was successfully
enucleated with referring to these diagrams.
Results : The operation time was 454 minutes. Five units of fresh frozen plasma was transfused
intraoperatively. Although she suffered refractory ascites which needed repeated paracentesis, she
managed to leave the hospital two months after the operation.
Conclusion : Creating a mirror image anatomy enables surgeons to safely perform a complex
hepatectomy in a patient with situs inversus totalis.
Key words : Situs inversus totalis・Hepatectomy・Hepatocellular carcinoma・Mirror image
Introduction
Resecting a hepatic tumor in patients with situs
inversus totalis is technically challenging because
they have a complete mirror image anatomy1)~4),
especially when the tumor was located deep in the
hepatic ducts in a situs inversus totalis patient.
Preoperatively creating mirror images of the liver
helped us easily recognize these intrahepatic
structures.
Case Report
liver. If intrahepatic vessels and biliary system
A 66-year-old female with situs inversus totalis
were incorrectly identified in such patients,
was diagnosed as having a hepatocellular carcino-
serious complications would ensue. We performed
ma, 5 cm in diameter, located deep just above the
a hepatecomy for a tumor located just above the
hepatic hilum (Fig. 1). The tumor compressed the
hepatic hilum compressing the right and left
right and left hepatic duct. In order to simply
Corresponding author contact information : Hideaki UCHIYAMA
Department of Surgery, Fukuoka City Hospital Fukuoka 812-0046, Japan
Phone ; +81-92-632-1111 Fax ; +81-92-632-0900
E-mail ; [email protected] med. kyushu-u. ac. jp
Hepatectomy in a situs inversus totalis patient
Fig. 1
Table 1
431
A : Contrast-enhanced CT of the patient
The tumor was located deep just above the
hepatic hilum compressing the inverted right
and left hepatic ducts. There was a moderate
amount of ascites.
Ant., the inverted anterior branch of the right
portal vein ; PV, the portal vein
Preoperative laboratory data of the patient
total bilirubin (mg/dl)
aspartate aminotransferase (IU/L)
alanine aminotransferase (IU/L)
alkaline phosphatase (IU/L)
albumin (g/dl)
white blood cell (/µl)
hemoglobin (g/dl)
platelet (× 103/µl)
items
preoperative value
1.53
90
normal range
0.30-1.20
13-33
61
893
3.5
4100
11.7
124
6-30
115-359
4.0-5.0
4000-8000
11.3-14.9
120-380
prothrombin time (%)
indocyanine green dye retention at 15 minutes (%)
alphafetoprotein (ng/ml)
des-gamma-carboxy prothrombin (mAU/ml)
80
22
57.7
314
70-140
0-10
0.0-20.0
0.0-40.0
understand the anatomy of this patient, we called
ascites was controlled by diuretics and albumin
the left-sided hepatic duct the inverted right
administration. We preoperatively created dia-
hepatic duct, and the right-sided hepatic duct the
grams of the mirror image anatomy, presupposing
inverted left hepatic duct. The liver which had
she had an ordinary anatomy (Fig. 2).
been infected with hepatitis C virus was in a
On entering the abdominal cavity, the liver was
condition of decompensated cirrhosis with a
substantially cirrhotic and there was still a
moderate amount of ascites. The preoperative
moderate amount of ascites. Intraoperative ultra-
laboratory data are summarized in Table 1.
sound confirmed a deep located tumor just above
Although we suggested that only a liver trans-
the hepatic hilum compressing the inverted right
plant would yield a long-term prognosis, she
and left hepatic ducts and just under the middle
stubbornly refused to undergo a transplant and
hepatic vein. First, the liver was divided along the
hoped for the resection of the tumor. We
Cantlie line in order to expose the right side of the
performed an enucleation hepatectomy after the
tumor. During the parenchymal transection, the
432
H. Uchiyama et al.
ascites which needed repeat paracentesis.
Nonetheless, she managed to return to her home
two months after the operation.
Discussion
Surgeon obtains their surgical skills mainly
through tactile and visual perception. In performing a surgery in a patient with situs inversus
totalis, these perception have to change to a
complete mirror image, which makes surgeons
confused and may lead to incorrect identification
of intrahepatic vessels and, as a result, to serious
complications. We preoperatively drew the mirror image diagrams of the hepatic anatomy of this
patient and made the operative plan about how to
resect the tumor. First, we imagined how the
tumor could be resected using the mirror image
diagrams, presupposing the patient had an
Fig. 2
Diagrams of hepatic anatomy of the patient
(right-hand) and mirror image diagrams
(left-hand)
The left-hand diagrams are the mirror images
of hepatic anatomy of this situs inversus totalis
patient. These diagrams depict ordinary hepatic
anatomy.
LHD, the left hepatic duct ; MHV, the middle
hepatic vein ; RHD, the right hepatic duct
ordinary anatomy. For convenience, we called the
left-sided hepatic artery (the right hepatic artery
in an ordinary anatomy) the inverted right hepatic
artery, the right-sided artery (the left hepatic
artery in an ordinary anatomy) the inverted left
hepatic artery. Similarly, the left-sided hepatic
duct was called the inverted right hepatic duct
and the right-sided hepatic duct was called the
middle hepatic vein was encountered and it was
inverted left hepatic duct. Then, we imagined the
ligated and divided. Once the right side of the
actual procedures using the true diagrams of
tumor was exposed, the tumor was freed from the
hepatic anatomy of this patient. Fortunately, the
surrounding liver parenchyma along the tumor
patients had no hepatic vascular and biliary
capsule. The inverted right and left hepatic ducts
anomalies. These were complete mirror images of
were individually encircled with a tape. These
an ordinary anatomy. Patients with situs inversus
ducts was sharply freed from the tumor using
totalis often have anomalies of their vascular and
scissors. Then, a new plane of parenchymal
biliary systems5). Precise preoperative imaging
transection was created in order to expose the left
and planning are crucial for resecting hepatic
side of the tumor. After the left side of the tumor
tumors in such patients.
was exposed, the caudal portion of the tumor was
Recent advancements of computer graphics
sharply dissected from the surrounding liver
have enabled even surgeons to easily create
parenchyma, then the tumor was taken out of the
anatomical diagrams and generate mirror images
surgical field. The operation time was 454 min.
by simply clicking a reverse button on a
and the intraoperative blood loss was 1427g
computer. Once we created these diagrams,
(including ascites). Five units of fresh frozen
preoperative planning of the procedures could be
plasma was transfused intraoperatively.
easily accomplished. Then, we could safely
The patient postoperatively suffered refractory
enucleate the tumor even though it was located
Hepatectomy in a situs inversus totalis patient
deep in the liver.
3)
In conclusion, creating a mirror image anatomy
enables surgeons to safely perform a complex
hepatectomy in a patient with situs inversus
totalis.
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(Received for publication October 4, 2013)
434
H. Uchiyama et al.
(和文抄録)
鏡面画像を利用した完全内臓逆位患者に対する肝切除の 1 例
1)
福岡市民病院外科
九州大学大学院消化器・総合外科
3)
九州大学病院別府病院外科
4)
熊本大学大学院消化器外科
2)
内 山 秀 昭 1),調
憲 2),吉 住 朋 晴 2),池 上
徹 2),副 島 雄 二 2),池 田 哲 夫 2),
川 中 博 文 2),山 下 洋 市 2),森 田
勝 2),沖
英 次 2),三 森 功 士 3),杉 町 圭 史 3),
佐 伯 浩 司2),渡 邊 雅 之4),竹 中 賢 治1),前 原 喜 彦2)
【背景】完全内臓逆位患者に対する肝切除は,通常解剖とは完全に鏡面の解剖となるため,特に腫瘍
が肝臓の深部に存在する場合には技術的に困難である.肝内脈管や胆道系の誤認は重篤な合併症
に繋がる恐れがある.今回我々は完全内臓逆位患者に対する肝切除を,コンピュータで作成した鏡
面像を利用しながら行った 1 例を経験したので報告する.
【方法】症例は 66 歳女性で,C 型肝炎の経過観察中,肝門部直上の深部に存在する,左右肝管を圧
迫する 5cm の肝細胞癌を指摘された.肝臓は中等量の腹水を伴う肝硬変で,肝移植を提示したが
拒否され,切除を強く希望した.術前に複数の鏡面画像をコンピュータで作成し,通常解剖と仮定
した上での手術計画を立てた.この鏡面画像を参照しながら腫瘍を核出した.
【結果】手術時間は 454 分で,術中 5 単位の新鮮凍結血漿を輸血した.術後は難治性腹水を合併し,
腹水穿刺を必要としたが,術後 2 か月で自宅退院した.
【結語】完全内臓逆位患者に対する肝切除を行う際,鏡面画像を作成することは,日ごろ親しんでい
る通常解剖で手術計画を立てることができ,複雑な肝切除もより安全に手術を行うことが可能とな
る.