Yuan et al.

World Journal of Surgical Oncology (2018) 16:173

https://doi.org/10.1186/s12957-018-1473-8

CASE REPORT Open Access

Retrolaparoscopic adrenalectomy assisted

by three-dimensional reconstructed digital
model in a patient with situs inversus
totalis
Xiaobin Yuan, Bin Zhang, Caoyang Hu, Xuhui Zhang and Dongwen Wang*

Abstract
Background: Situs inversus totalis is a relatively rare congenital anomaly. Performing the retrolaparoscopic adrenalectomy
for the patient with situs inversus totalis is a skill-demanding and challenging surgical task, which has been even more
rarely reported.
Case presentation: We present a case with a large right adrenal mass (10.2 × 9.4 × 7.9 cm) complicated by situs inversus
totalis. This 59-year-old female patient underwent the retrolaparoscopic adrenalectomy in our department. In order to
facilitate the surgical orientation and improve the manipulating accuracy, the data from computed tomography images
was extracted and the three-dimensional digital model was reconstructed. Under the assistance of preoperative planning
and intraoperative navigation by the three-dimensional digital model, the retrolaparoscopic adrenalectomy was technically
precise and successful. The targeted adrenal tumor was excised completely with final pathological diagnosis of
adrenocortical adenoma.
Conclusions: Retrolaparoscopic adrenalectomy can be performed safely in patients with situs inversus totalis. The
assistance of preoperative planning and intraoperative navigation by the reconstructed three-dimensional digital
model can facilitate the operation and lead to more precise vessel manipulation and accurate excision of tumor
that is both effective and safe.
Keywords: Situs inversus totalis, Adrenalectomy, Retrolaparoscopic surgery, Adrenal adenoma, Digital model

Background adrenalectomy via retroperitoneal way instead of transper-

Situs inversus totalis (SIT) is a relatively rare congenital itoneal way, and has the biggest reported adrenal tumor
anomaly characterized by the complete mirror-imaged mass in SIT patient by far.
visceral organs in the opposite anatomic positions [1],
and its incidence was reported to be in the range of
1:10000 to 1:20000 [2]. There are only four published Case presentation
papers that described the laparoscopic adrenalectomy A 59-year-old female patient was admitted into our hospital
for adrenal mass in the patients with SIT [3–6], but they for the abnormal computed tomography (CT) image
were all finished via the transperitoneal approach. Here, presentation of right adrenal mass revealed by occasional
we present a rare case of a much larger adrenal tumor health examination, accompanied with the complaint of
(10.2 × 9.4 × 7.9 cm) with SIT who underwent the retrola- intermittent nausea and blurred vision. She had been
paroscopic adrenalectomy. To the best of our knowledge, diagnosed with SIT when she received the hysterectomy
our case is the first report that received the laparoscopic and near-total thyroidectomy for the uterus myoma and
thyroid cancer in 2000. Besides, her past medical history
also included the diabetes mellitus (type 2) for 6 years and
* Correspondence: urology2007@126.com
Department of Urology, First Hospital of Shanxi Medical University, No. 85, significant hypertension for 5 years, ranging from 150 to
Jiefangnan Road, Taiyuan 030001, Shanxi, China 200/90 to 102 mmHg, fluctuated periodically.
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Yuan et al. World Journal of Surgical Oncology (2018) 16:173 Page 2 of 5

The patient’s height was 158.0 cm and the body weight The tumor can be shadowed and turned into a trans-
was 70.0 kg. The BMI was 28.04 kg/m2, which was well parency, leaving the hollow-shaped crater. A more distinct
correlated with her significant abdominal obesity. The spatial relationship between the adrenal mass and the
laboratory tests presented the normal levels of the serum nearby structures showed clearly via this intraparenchymal
potassium concentration (4.2 mEq/L) and the renin visualization. Based on these data, we tailored a specific
activity (3.8 ng/mL/h). The plasma cortisol and aldoster- surgical plan for this rare case. The surgeons can gain a
one (217 pg/mL) concentrations were also within the refer- full comprehension of the regional complexity which is
ence range. Besides, there were no abnormalities found in mirrored to the normal anatomy.
the levels of the urinary catecholamines (59.2 mcg/24 h) The retrolaparoscopic adrenalectomy was performed
and vanillylmandelic (4.3 mg/24 h) either. at the Department of Urology. The patient was placed
As for the medical image examinations, the routine on the operating table in the lateral decubitus position
chest X-ray image revealed the dextrocardia; the dual- with the affected side upward. The general anesthesia and
source 64-slice enhanced CT (LightSpeed VCT, GE Health- tracheal intubation were administrated. After padding the
care, USA) scan including arterial phase, venous phase, and pressure points with beanbags and fixing the posture with
excretory phase after intravenous contrast administration the optimal table flexion, a longitudinal 1.5 cm incision
confirmed the diagnosis of SIT and presented her round- for 12 mm trocar was made in the posterior axillary line
shaped mass on the right adrenal gland with the size of below the 12th rib. In order to minimize the potential irri-
10.2 × 9.4 × 7.9 cm (Fig. 1). tation to the stability of blood pressure, the retroperitoneal
In order to facilitate the surgical orientation and improve space was dilated in the blunt finger-dissecting style
the manipulating accuracy, the data from CT images was instead of the traditional ballooning way. Another two
extracted and the three-dimensional digital model (3D-DM) 12 mm trocars were located at the point of 2 cm above
was reconstructed: The original image data from CT from iliac crest superior border in the mid-axillary line for
scanning was set in the format of Digital Imaging and the laparoscope, and at the point under the subcostal
Communications in Medicine (DICOM). The copied margin in the anterior axillary line for laparoscopic instru-
information was analyzed and reconstructed into the ments respectively. After the routine insertion of three
3D-DM by using a postprocessing software named trocars and the establishment of pneumoperitoneum at a
three-dimensional medical image reconstructing and pressure of 10 mmHg, the retroperitoneal fat tissue was
guiding system (3D-MIRGS, China), which is a multi- removed under the laparoscopic surveillance. Another
functional workstation for the clinical application, whose assisted 5 mm trocar was inserted due to the patient’s
functions included CT-based image reconstruction, pre- obesity. A well-trained full-time surgical technician
operative planning, and intraoperative-assisted navigation captured some typical screenshots to illustrate the ana-
[7]. The retroperitoneal space along with critical anatomic tomical landmarks. Then, the semitransparent 3D-DM
structures including adrenal tumor, the relevant vascula- were superimposed onto these screenshots with appropri-
ture, the kidney, and the renal collecting system on the ate axis and size adjustments. The composite 3D-DM
affected side were reconstructed and marked by using images provided the surgeon with information relative to
different colors simultaneously (Fig. 2). the inverted anatomy, thereby acting as a kind of assisted
The morphometric calculation and analysis of the recon- navigation for the subsequent manipulations. All these
structed 3D-DM provided the surgeons with the valuable speedy manual image fusions performed synchronously
anatomic information such as the spatial locations of vital during operation and all the fused images were displayed
vessels, maximal diameter, and margins of the adrenal mass. on a separate screen. Under the assisted navigation of

Fig. 1 The CT findings. Situs inversus totalis was confirmed, and a mass of about 10 cm in diameter in contact with the right adrenal gland was
detected. a Dextrocardia (black arrow: cardiac apex). b The axial plane (white arrow: the targeted adrenal mass). c The coronal plane (white arrow:
the targeted adrenal mass)
Yuan et al. World Journal of Surgical Oncology (2018) 16:173 Page 3 of 5

Fig. 2 a, b The three-dimensional digital model (3D-DM) was reconstructed using different colors (white arrows: the central vein of adrenal
gland). c The intraoperative fused vasculature featured the targeted central vein of adrenal gland (the white arrow). d, e Identifying and clamping
the central vein of adrenal gland (the white arrows)

3D-DM, the Gerota fascia was incised and the adrenal Discussion
central vein was dissected carefully, following its ligation After more than two-decade global verification via massive
by using 5 mm Hem-o-lok clips. After that, the mass was clinical practice, laparoscopic adrenalectomy has been
excised completely with the careful preservation of normal viewed as the gold standard [8] of surgical treatment
adrenal tissue and the other adrenal vessels including for adrenal masses since the first report by Gagner et al.
the adrenal arteries were ligated and scissored up. Then, [9] in 1992. Many reports have proven the effectiveness
the retroperitoneal pressure was set down to the level of and safety of transabdominal laparoscopic adrenalectomy
5 mmHg and the hemostasis was achieved carefully. Given and its well tolerance to a broad spectrum of functioning
the size of the tumor mass and the skin elasticity, we and non-functioning adrenal diseases [10, 11]. The moti-
extended the incision below the 12th rib along its axis for vations for less irritation to the bowel function and faster
the total length about 7 cm. The specimen of adrenal postoperative recovery, together with the improvements
tumor was packed into a homemade laparoscopic pouch in endo-surgical techniques and experiences, have sup-
with a string by graspers and then was withdrawn by hold- ported the feasibility and safety of retrolaparoscopic way
ing and pulling the string vigorously. The trocar incisions for adrenalectomy, with no exception to this challenging
were carefully closed, and a rubber drainage catheter was task of endoscopic resection to the large adrenal tumor
left in situ. complicated with SIT.
The operative time was 1 h and 10 min, with no intra- To the dextromanual surgeons, the mirror-imaged
operative complications happened. The estimated blood anatomy of SIT patient always indicates the technical
loss was about 10 mL. The size of resected tumor was challenges in endoscopic orientation and maneuvers.
10.0 × 9.1 × 6.8 cm, and no gross extracapsular invasion The inefficient familiarity to the abnormal disposition
was found. The final pathological diagnosis was adreno- of organs and the consequent reduced self-confidence
cortical adenoma (Fig. 3). The postoperative course was in the surgical manipulations will lead to more cautious
uneventful, and the patient was discharged after 4 days and repeated spatial confirmations, which can result in
postoperatively. A video demonstrating the operation the prolonged operative course inevitably [12, 13]. Besides,
accompanies this article (Additional file 1). the mirror-imaged anatomy also requires to rearrange the
Yuan et al. World Journal of Surgical Oncology (2018) 16:173 Page 4 of 5

Fig. 3 a The size of resected tumor was 10.0 × 9.1 × 6.8 cm, and no gross extracapsular invasion was found. b The final pathological diagnosis
was adrenocortical adenoma

positionings of the surgeons and the surgical devices to In our future clinical practice, we believe the robotic
facilitate the operation. retrolaparoscopic adrenalectomy might be helpful to these
To ensure a safe and smooth surgical procedure, accur- rare cases. The centered robotic view of the surgical field
ate preoperative anatomic comprehension and adequate can eliminate the difficulty of changing instruments in
preoperative planning work are useful and pivotal. In this both hands [14].
context, our surgeon team held a routine session to
formulate a suitable surgical blueprint for this case based Conclusions
on the information gained from the detailed morphometry Retrolaparoscopic adrenalectomy can be performed safely in
of the reconstructed 3D-DM preoperatively. The surgical patients with SIT. The assistance of preoperative planning
plan consists of four parts: the planning of acquainting and intraoperative navigation by the reconstructed 3D-DM
with the mirror-imaged retroperitoneal space, the plan- can facilitate the operation and lead to more precise vessel
ning of confirming and dissecting the central vein of manipulation and accurate excision of tumor that is
the adrenal gland, the planning of accurate adrenal both effective and safe.
mass excision with maximal preservation of the normal
adrenal tissue, and the planning of avoiding damage to Additional file
the inverted proximal anatomical structures. The most
accurate information about the mirror-imaged regional Additional file 1: The 3D-DM guided preoperative planning and the
anatomy featuring the valuable warning landmarks where intraoperative video. (WMV 57228 kb)
potential surgical injury may occur will be noticed and
emphasized. It has been proven to be helpful and could Abbreviations
3D-DM: Three-dimensional digital model; CT: Computed tomography;
achieve a more ample preparation by walking through the DICOM: Digital Imaging and Communications in Medicine; SIT: Situs inversus
surgical procedure in this style prior to the operation. totalis
Compared with the conventional CT scanned images,
Availability of data and materials
3D-DM helped the surgeon to generate an improved All data generated or analyzed during this study are included in this
and more detailed surgical blueprint in his mind, which manuscript.
undoubtedly increased his comprehension and confidence
on the upcoming operation and eventually resulted in Authors’ contributions
DW was the main surgeon of the operation and conceived of the study. CH
the reducing of the tentative maneuvers in the vessel- and XZ were the assisted surgeons of the operation. XY collected the clinical
controlling and tissue-dissecting procedures. Moreover, data and participated in the coordination and drafted the manuscript. BZ
when it came to many surgical decision-making occasions reconstructed the three-dimensional digital model. All authors read and
approved the final manuscript.
in the operation, the rapid feedback according to the
information provided by 3D-DM shortened the evaluating Ethics approval and consent to participate
time efficiently on the premise of safety. The study was approved by the institutional ethics board of the First
Hospital of Shanxi Medical University.
Nevertheless, we still recommend that SIT-involved
retrolaparoscopic adrenalectomy should be performed by Consent for publication
the experienced laparoscopic surgeon, as the intraoperative Written informed consent was obtained from the patient for the publication
of this case report and any accompanying images.
fast and suitable solution to the SIT-initiated spatial
orientation problems still mostly rely on the professional Competing interests
attainment and surgical skills of the surgeon. The authors declare that they have no competing interests.
Yuan et al. World Journal of Surgical Oncology (2018) 16:173 Page 5 of 5

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.

Received: 10 April 2018 Accepted: 9 August 2018

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