Combined liver–kidney transplantation using a situs inversus totalis donor liver: Retroversus implantation: A case report

Situs inversus totalis is a rare congenital anomaly where thoracic and abdominal organs are completely reversed in mirror-image orentation. While it does not preclude transplantation, it presents significant technical challenges, especially in liver transplantation, due to the altered orientation of vascular and biliary structures. We present a case involving a 50-year-old man with end-stage renal disease and advanced cholestatic cirrhosis. His model for end-stage liver disease score was 26, qualifying him for combined liver-kidney transplantation. A donor with SIT became available, and pre-donor evaluation confirmed complete SIT with typical vascular and biliary anatomy. The donor liver weighed 900 g. During orthotopic positioning, the alignment was unfavorable, necessitating the graft to be implanted in a retroversus orientation to restore optimal anatomical relationships. Vascular reconstructions included an end-to-side piggyback cavocaval anastomosis, an end-to-end portal vein reconstruction, and an arterial anastomosis between the donor common hepatic artery and the recipient's right hepatic artery originating from the superior mesenteric artery. Biliary continuity was established through duct-to-duct anastomosis. Subsequently, kidney transplantation was performed in the right iliac fossa using the donor's right kidney. No blood transfusions were needed, and the postoperative recovery was smooth. Both grafts functioned normally, and the patient was discharged on postoperative day 12. At the 9-month follow-up, liver and kidney functions remained excellent. Retroversus implantation enabled successful combined liver-kidney transplantation using a donor liver from a patient with SIT. This case underscores the necessity for meticulous planning, intraoperative adaptability, and technical modifications to ensure safe transplantation in anatomically challenging situations.