Laparoscopic Nissen fundoplication in situs inversus totalis: Technical and ergonomic issues

We report a laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD) in a patient with situs inversus totalis (SIT). A 34-year-old man was diagnosed with SIT on performing chest X-ray and abdominal sonography as a routine preoperative investigations. He presented with chronic gastro-esophageal reflux disease (GERD) inadequately controlled by medications. The laparoscopic procedure was performed using five ports placed in a mirror-image configuration and with the patient in the modified lithotomy position. Few technical difficulties were encountered during the operation. The position of the primary surgeon, working between the lower limbs of the patient as in case of standard fundoplication, was considered most prudent position to the success of this case. In SIT, this position provides the least visual disorientation from the reversed abdominal organs. We recommend that preoperative detection of SIT is essential to understand the symptomatology of the patient and for planning of any upper abdominal laparoscopic procedure.