Thoracoscopic right upper lobectomy in a patient with situs inversus totalis

Situs inversus totalis (SIT) is a rare congenital anomaly with an incidence ratio of 1 : 4,000–1 : 60,000 births. It is characterised by the dislocation of the internal organs to the contralateral side of the body in relation to the median plane [1]. Video-assisted thoracoscopic surgery (VATS) is the recommended approach for the treatment of early-stage non-small cell lung cancer (NSCLC) [2, 3]. Variations in the lung anatomy of patients with SIT may complicate the resection of the lung, particularly when performed using a VATS approach.
A 65-year-old male with SIT was referred for the treatment of a tumour in the right upper lobe of the lung. His medical history revealed arterial hypertension, chronic obstructive pulmonary disease, and coronary heart disease.
Computed tomography (CT) of the chest revealed a 4.9 × 4.4-cm mass in the right upper lobe of the lung. The right lung displayed a typical left lung anatomy, with 2 lobes and a long main bronchus passing below the aortic arch. A single atypical vein could be seen passing from the lingula to the right lower pulmonary vein. However, a lingular bronchus originated from the right upper lobe bronchus. The location of the internal organs, including heart, great vessels, liver and spleen, was typical of that in SIT (Figure 1). Positron emission tomography – computed tomography (PET-CT) using 18F-FDG confirmed a 5.1 × 4.5-cm tumour with a standardised uptake value of 12.5 (Figure 2). Percutaneous CT-guided tumour biopsy established the diagnosis of squamous cell lung cancer. According to the 8th edition of the TNM classification, the stage of the cancer was cT3, N0, M0.
The results of pulmonary function test were as follows: forced expiratory volume in 1 s (FEV1) 2.25 l (75%) and vital capacity (VC) 3.57 l (95%). Diffusion capacity for carbon monoxide was 9.82 mmol/min/kPa (118%). Apart from SIT, no other abnormalities were revealed using bronchoscopy, abdominal ultrasonography, electrocardiography, or echocardiography.
Surgery was performed under general anaesthesia. A left-sided double-lumen endotracheal tube was placed under the guidance of fibreoptic bronchoscopy, and single-lung ventilation was initiated. The 3-portal VATS approach was used. The well-developed, posterior part of the interlobar fissure was divided using LigaSure (Medtronic, Minneapolis, MN, USA). Next, the common lingular artery was divided using an endostapler (SigniaTM, Tri-StapleTM, Medtronic, Minneapolis, MN,...


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