Modified Piggy-Back Technique for Orthotopic Liver Transplantation in a 67-Year-Old Woman with Situs Inversus Totalis: A Case Report.

BACKGROUND Situs inversus totalis (SIT) is a rare congenital condition characterized by complete mirror-image reversal of the thoracic and abdominal organs. This anatomical anomaly poses unique challenges for major abdominal surgeries, particularly liver transplantation, due to altered vascular and visceral orientation. While successful liver transplantations in patients with SIT have been reported, technical guidance remains limited. CASE REPORT We report a case of a 67-year-old woman with end-stage liver disease due to idiopathic cirrhosis and complete SIT. She had a prior splenectomy, hepatocellular carcinoma treated with transarterial chemoembolization, and a preoperative MELD score of 40. A full-size graft from a donation after brain death donor was used. The transplantation was performed using a modified piggy-back technique, without venovenous bypass. Due to reversed anatomy, a wide triangular end-to-side cavo-caval anastomosis was applied to ensure venous outflow. The graft was positioned in the left upper quadrant, without fixation. Vascular and biliary anastomoses were completed without tension or kinking. Total operative time was 485 min, with minimal blood loss. Postoperative recovery was uneventful, and the patient was discharged on day 77. Six-month follow-up revealed no complications. CONCLUSIONS Liver transplantation in patients with SIT is feasible and safe when appropriate technical modifications are used. The modified piggy-back technique provides a reliable solution for venous reconstruction and graft stability in the context of reversed anatomy.