How to do liver transplantation in situs inversus totalis: a simple technique

Situ inversus totalis (SIT), a defect in the global situs orientation resulting in a complete mirror image of the normal arrangement of internal organs, occurs in one out of 4000–20 000 newborns. Due to its rarity and complexity, SIT presents a unique technical challenge. The main problems for orthotopic liver transplantation in SIT are: (i) having to place the greater right lobe of the graft over the right-sided stomach; and (ii) the presence of a large empty space in the left upper quadrant predisposing to lateral displacement of the graft leading to kinking of the hepatic veins. Raynor et al. reported the first successful liver transplant in a recipient with SIT in 1988. Though different successful approaches have been proposed, agreement on a standard technique has not been achieved. They are: (i) plication of the left diaphragm together with stabilization of the graft with an inflated gastric balloon of the Sengstaken–Blakemore tube inserted percutaneously; (ii) segmental living donor liver transplantation (i.e. reduced size); (iii) varying degrees (15–90°) of lateral rotation (clockwise in SIT recipients or counterclockwise in donor SIT) of the graft with standard piggy-back, end-to-side or