A Case of Advanced Esophageal Cancer With Situs Inversus Totalis Successfully Treated With Thoracoscopic Subtotal Esophagectomy

Background Situs inversus totalis (SIT) is a rare disorder characterized by the transposition of the thoracic and abdominal organs to the opposite side of the body, in a mirror image of the normal anatomy. The incidence of SIT is approximately 0.005%–0.01% of all live births. Its occurrence makes surgical procedures more challenging owing to the mirror image positioning of organs. Methods A 79-year-old male with a history of rheumatoid arthritis (on immunosuppressive therapy for 17 years), emphysema, and hypothyroidism presented with hoarseness. Chest X-rays revealed dextrocardia. Gastrointestinal endoscopy (GIE) revealed a type 2 lesion located 25 to 37 cm from the incisor teeth, and biopsy confirmed squamous cell carcinoma. Enhanced CT revealed complete situs inversus, esophageal wall thickening, and enlarged regional lymph nodes, with a clinical stage of cT3, N3, M0, cStage III. Neoadjuvant chemotherapy with the DCF regimen was administered for two courses. Results The surgery was carried out under general anesthesia combined with epidural anesthesia and differential lung ventilation. The patient was positioned in the right lateral decubitus position, with the surgeon standing on the patient’s left side. A small incision was made along the mid-axillary line at the fifth intercostal space, and a Lap-Protector Mini TM was placed (for the camera or the first assistant’s right hand). Five additional ports were placed. The primary surgeon is positioned on the dorsal side of the patient (right side of the image), while the assistant and scopist are positioned anteriorly. The surgery was then initiated. Conclusion We performed thoracoscopic subtotal esophagectomy for a patient with situs inversus totalis and esophageal cancer. In cases of SIT, thorough preoperative understanding of the altered anatomy is essential for safe left thoracotomy. However, anatomical misidentification can still occur intraoperatively, even with adequate preparation; therefore, such procedures should ideally be performed by an experienced surgical team.