Ann Hepatobiliary Pancreat Surg.  2020 Aug;24(3):319-325. 10.14701/ahbps.2020.24.3.319.

Deceased donor liver transplantation in an adult recipient with situs inversus totalis: A case report of 10-year clinical sequences following primary and repeat transplantation

• Na BG
• Hwang S
• Ahn CS
• Moon DB
• Song GW
• Jung DH
• Park GC
• Lee SG

• KMID: 2505335
• DOI: http://doi.org/10.14701/ahbps.2020.24.3.319

Abstract

The feasibility of liver transplantation (LT) in adult patients with situs inversus (SI) was demonstrated with advances in surgical techniques. However, SI is very rare, and the experience of LT in adult patients with SI is very limited. We present a case of an adult patient with SI who underwent deceased-donor LT and late retransplantation because of chronic rejection. A 42-year-old man with SI totalis who suffered from acute-on-chronic hepatic failure because of hepatitis B virus-associated liver cirrhosis and alcoholic liver disease was referred to our center and underwent successful orthotopic deceased-donor whole-liver transplantation. We used a modified piggy-back technique with cavo-cavostomy and inserted a tissue expander for mechanical support of the unstably located liver graft. The patient recovered uneventfully. At 3 years after the first LT, this patient underwent retransplantation because of chronic rejection. In the second LT, we used similar surgical techniques, but performed splenectomy to make space to accommodate the second liver graft. The patient was discharged after long hospitalization. At 5 years after the second LT, he underwent living-donor kidney transplantation because of chronic renal failure developed after the second LT. Currently, he has done well for 10 years after the first LT. In conclusion, SI is a rare anomalous condition hindering LT. Careful perioperative planning with thorough assessment of the donor and recipient livers and use of patient-tailored surgical techniques can lead to successful LT.

Keyword

Liver anatomy; Liver transplantation; Whole liver; Malrotation; Cavoplasty

Figure

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  Fig. 1 Pretransplant computed tomography findings showing situs inversus totalis with dextrocardia (A) and mirror-image rotation of the abdominal viscera (B).

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  Fig. 2 Intraoperative photographs of graft outflow vein reconstruction using a modified piggyback method. (A) The orifices of the right, middle, and left hepatic vein trunks were opened, and a 5-cm-long longitudinal incision was made at the ventral surface of the retrohepatic inferior vena cava (IVC). (B and C) The corners of the recipient and graft IVC orifices were tagged with 4-0 Prolene sutures, and then a 4-cm-long longitudinal incision was also made at the dorsal surface of the graft IVC. (D and E) These triangular-shaped orifices at the recipient and graft IVCs were matched and then sutured with 4-0 Prolene. (F) The left side of the IVC anastomosis was performed with 4-0 Prolene.

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  Fig. 3 Intraoperative photographs of graft hilum reconstruction. (A) The portal vein was anastomosed under this orientation with gauze packing. (B) Hepatic artery reconstruction and duct-to-duct anastomosis was done with insertion of a rubber T-tube. (C and D) A large tissue expander was placed at the left subphrenic space for mechanical support of the liver graft.

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  Fig. 4 Posttransplant computed tomography taken 10 days after the first transplantation, showing uneventful reconstruction of the hepatic vein (A) and portal vein (B).

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  Fig. 5 Posttransplant computed tomography taken 30 months after the first transplantation, showing uneventful hepatic vein (A and C) and portal vein (B and D) anastomoses. The spleen was markedly enlarged.

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  Fig. 6 Posttransplant computed tomography taken 7 days after retransplantation, showing uneventful reconstruction of the hepatic vein (A and C) and portal vein (B and D). The central portion of the liver showed ischemic changes.

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  Fig. 7 Posttransplant computed tomography taken 6 years after retransplantation, showing uneventful hepatic vein (A) and portal vein (B) anastomoses.

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