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Background <p>Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete mirror-image transposition of the thoracic and abdominal viscera. Pancreaticoduodenectomy (PD), also known as the Whipple procedure in patients with SIT is technically challenging because of altered anatomical orientation. We report the first case of PD for ampullary adenocarcinoma in a patient with SIT from Sri Lanka.</p> Case presentation <p>A 72-year-old male presented with painless progressive obstructive jaundice and anorexia of one month’s duration. Cross-sectional imaging demonstrated situs inversus totalis and a distal common bile duct obstruction caused by an ampullary lesion. Following biliary decompression and prehabilitation, the patient underwent open PD with mesopancreatic excision. Reconstruction was performed using a modified Blumgart duct-to-mucosa pancreaticojejunostomy, end-to-side hepaticojejunostomy and gastrojejunostomy. Operative duration was 8&#xa0;h and 45&#xa0;min with an estimated blood loss of 300&#xa0;ml. Histopathological examination demonstrated an intestinal-type ampullary adenocarcinoma measuring 35 × 17 × 12&#xa0;mm. A total of 15 regional lymph nodes were examined, with 5 positive lymph nodes. Lymphovascular invasion was present and perineural invasion was absent. The tumour was staged according to the AJCC 8th edition as pT3N2, and all resection margins were negative (R0). The patient initially recovered and was discharged from the intensive care unit on postoperative day 4. However, he developed severe hospital-acquired bilateral pneumonia requiring ICU readmission and mechanical ventilation on postoperative day 7 and subsequently died of respiratory failure on postoperative day 25.</p> Discussion <p>PD in patients with SIT requires meticulous preoperative planning, detailed understanding of mirror-image anatomy, and adaptation of operative strategy. Careful interpretation of preoperative imaging facilitates safe execution of this complex procedure.</p> Conclusion <p>PD is technically feasible in patients with situs inversus totalis when supported by thorough preoperative assessment and careful operative planning. However, major postoperative complications remain an important determinant of overall outcome following pancreatic surgery.</p>

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Operating on a mirror image: First report of pancreaticoduodenectomy for periampullary adenocarcinoma in situs inversus totalis from Sri Lanka

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  • 发表日期：

    2026年7月13日

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  • Duminda Subasinghe,
  • Harry Prashath,
  • Nilesh Fernandopulle,
  • Vihara Dassanayake,
  • Sivasuriya Sivaganesh

摘要

Background

Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete mirror-image transposition of the thoracic and abdominal viscera. Pancreaticoduodenectomy (PD), also known as the Whipple procedure in patients with SIT is technically challenging because of altered anatomical orientation. We report the first case of PD for ampullary adenocarcinoma in a patient with SIT from Sri Lanka.

Case presentation

A 72-year-old male presented with painless progressive obstructive jaundice and anorexia of one month’s duration. Cross-sectional imaging demonstrated situs inversus totalis and a distal common bile duct obstruction caused by an ampullary lesion. Following biliary decompression and prehabilitation, the patient underwent open PD with mesopancreatic excision. Reconstruction was performed using a modified Blumgart duct-to-mucosa pancreaticojejunostomy, end-to-side hepaticojejunostomy and gastrojejunostomy. Operative duration was 8 h and 45 min with an estimated blood loss of 300 ml. Histopathological examination demonstrated an intestinal-type ampullary adenocarcinoma measuring 35 × 17 × 12 mm. A total of 15 regional lymph nodes were examined, with 5 positive lymph nodes. Lymphovascular invasion was present and perineural invasion was absent. The tumour was staged according to the AJCC 8th edition as pT3N2, and all resection margins were negative (R0). The patient initially recovered and was discharged from the intensive care unit on postoperative day 4. However, he developed severe hospital-acquired bilateral pneumonia requiring ICU readmission and mechanical ventilation on postoperative day 7 and subsequently died of respiratory failure on postoperative day 25.

Discussion

PD in patients with SIT requires meticulous preoperative planning, detailed understanding of mirror-image anatomy, and adaptation of operative strategy. Careful interpretation of preoperative imaging facilitates safe execution of this complex procedure.

Conclusion

PD is technically feasible in patients with situs inversus totalis when supported by thorough preoperative assessment and careful operative planning. However, major postoperative complications remain an important determinant of overall outcome following pancreatic surgery.