Title : Laparoscopic fundoplication in visceral inversus: Overcoming right-sided liver–related exposure challenges
Abstract:
Introduction: Visceral inversus is a rare congenital condition characterized by mirror-image transposition of abdominal organs. Although laparoscopic fundoplication is an established treatment for gastroesophageal reflux disease, altered anatomy can introduce significant technical challenges, particularly in achieving adequate exposure of the esophagogastric junction.
Case Presentation: A 32-year-old male with visceral inversus presented with refractory GERD symptoms, including postprandial nausea and dysphagia. Preoperative evaluation using endoscopy, high-resolution manometry, 24-hour pH monitoring, and contrast-enhanced computed tomography confirmed severe pathological reflux, hiatal hernia, and right-sided positioning of the stomach and spleen. The patient underwent laparoscopic hiatal hernia repair with Toupet fundoplication using a mirror-image trocar configuration.
Intraoperatively, exposure of the esophagogastric junction was significantly limited due to the right-sided liver. Standard epigastric liver retraction was inadequate, necessitating the placement of an additional right-sided port for effective retraction. Following adhesiolysis and esophageal mobilization, posterior crural repair and Toupet fundoplication were successfully completed. The operative time was 3 hours 35 minutes with minimal blood loss.
The postoperative course was uneventful. At 3-month follow-up, the patient demonstrated marked symptomatic improvement with resolution of dysphagia and nausea, and only mild residual belching.
Discussion: Laparoscopic fundoplication in visceral inversus presents unique ergonomic and anatomical challenges. While mirror-image anatomy requires adaptation in port placement and surgeon positioning, this case highlights that organ-specific factors—particularly the position of the liver—may be the primary determinant of intraoperative difficulty. Standard mirror-image strategies alone may be insufficient, and tailored intraoperative modifications are often required.
Conclusions: Laparoscopic fundoplication in patients with visceral inversus is feasible and safe when appropriate technical adjustments are made. Surgeons should anticipate not only reversed anatomy but also organ-specific variations that may necessitate individualized operative strategies to ensure optimal exposure and outcomes.
