Pancreaticoduodenectomy for biliary tract carcinoma with situs inversus totalis: difficulties and technical notes based on two cases

Table 2 Difficulties and technical issues in pancreaticoduodenectomy in patients with situs inversus (totalis)

Step	Procedure	Difficulties	Appropriate techniques
Extirpation	Surgeon’s position	Mirror-imaged transposition of abdominal viscera	The surgeon stands on the right side of the patient.
	Vessel control	Vascular anomalies	Careful preoperative anatomic assessment by detailed imaging studies is needed.
	Vessel control	Vascular anomalies	It is helpful to encircle the major vessels and use them as landmarks, to avoid any errors.
	Handling technique	Left-to-right reversal of the standard procedure	Reconstructed imaging by MD-CT is useful for preoperative planning.
			The surgeon changes position depending on various situations.
			The assistants adequately support the operation.
Reconstruction	Pancreaticojejunostomy	Reversed suture technique	The surgeon decides the best position for suturing.
	Hepaticojejunostomy		The doubly armed sutures are useful in pancreaticojejunostomy.
	Duodenojejunostomy
Drainage	Route	Same routes as the standard procedure	Two closed-system drainages are placed in the foramen of Winslow and around the pancreaticojejunal anastomosis.

ISSN: 1477-7819