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Had it not been for the seven-centimetre-long tumour in Ashok Shivnani's right kidney, doctors at Lilavati, who were scheduled to operate

on him, would never have stumbled on a case that is rarer than rare in medical history.

Suspecting that something was not quite normal when they viewed the scans and X-rays of the tumour, the medicos ordered a two-dimensional echocardiogram and angiogram of the 64-year-old patient. It was then that they realised, to their shock, that most of his abdominal organs and blood vessels were either reversed or misplaced.

Shivnani's case comes closest to a rare congenital disorder called 'situs inversus', in which the organs of the chest and abdomen are arranged in a mirror-image reversal of normal positioning. Doctors say that he is, in all probability, the only person in the world to have such a haphazard abdominal structure.

The echocardiogram revealed that the positions of Shivnani's IVC (inferior vena cava, which brings impure blood to the heart and is on its right) and aorta (which takes pure blood from the heart and is on the left) were reversed.

"When I first saw the reports, I actually thought I was holding them wrong. Along with the reversed position of the aorta and IVC, the scans also showed that Shivnani had a second IVC coming out from the tumour-infected kidney, which joined the original IVC at the bottom of his abdomen. It would have been most difficult to proceed with the surgery under these circumstances," said Dr Anoop Ramani, the uro-oncologist surgeon, who performed the surgery on Shivnani.

"Not only was there a duplication of the IVC, but the IVC above the kidney was totally closed. While operating, we are supposed to know the exact location of everything we are going to touch. But in this case, we were not sure which veins were entering where," said Dr Prakash Sanzgiri, cardiologist from Lilavati. Hence, it became necessary to reschedule the surgery from January 29 to February 4, as the doctors needed more time to decide how to deal with the problem.

But that was not all. During the course of the surgery to remove the infected kidney, the doctors came across more startling facts about Shivnani's organ structure. There were three blood vessels which took blood to his infected kidney. He had no small intestine, and his large intestine was very small. His liver had also split into two parts, one on each side.

"We generally perform surgeries laparoscopically for renal cancer. It is difficult to perform the surgery even without the strange organ structure. Thankfully, we did a laparoscopic surgery, in which we could see everything ten times the actual size on the screen," said Dr Ramani. "It is the first time I have seen such a case in my 15-year career," he added.

However, the doctors maintained that Shivnani did not need any treatment for his abnormal organ structure. "Generally, people suffering from situs invertus lead a fairly asymptomatic life. This is also the case with Shivnani. He will not need any surgery to change the positions of the organs and veins," said Dr Desai.


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