situs inversus totalis ( sit ) is a rare congenital malformation characterized by transposition of organs to the opposite side of the body in the mirror image of normal . it occurs in 1:5,000 to 1:10,000 of hospital admissions , and although most patients are asymptomatic , it can be associated with a number of other conditions such as cardiac anomalies and kartagener 's syndrome [ 1 , 3 ] . the aim of this report is to describe the case of symptomatic cholelithiasis managed by three - port laparoscopic cholecystectomy in a woman from brazilian amazonia with sit . a 43-year - old woman , born and resident in brazilian amazonia , presented with a 15-day history of dolorous syndrome localized at the left hypochondrium and epigastrium with no other concomitant digestive problems . on physical examination , she was afebrile , without jaundice , and abdominal examination was unremarkable . during clinical assessment , abdominal ultrasonography showed situs inversus and hyperechogenic images in the gallbladder lumen , compatible with multiple free stones . was identified , diagnosis of sit and cholelithiasis was made and the dolorous syndrome was attributed to it . based on this diagnosis , the patient underwent three - port laparoscopic cholecystectomy by a left - hand surgeon . however , the surgical team and the laparoscopic devices were located as a mirror image configuration from the one used in orthotopic patients . the operating surgeon and the video monitor assistant were positioned on the patient 's right side and the tv monitor was placed on the upper left side of the patient . three ports were used : a 10-mm trocar was inserted infraumbilically through which the zero viewing endoscope was introduced . another 10-mm trocar was inserted 3 cm below the xiphisternum at midline ; and finally , a 5-mm trocar at the left hypochondrium hemiclavicular line 5 cm below the costal margin . the infraumbilical port was used to create the pneumoperitoneum ( 12 mm hg ) with carbon dioxide ( co2 ) . 2 ) . the operating surgeon held the dissecting instruments with his left hand through the 10-mm trocar while holding the gallbladder at the infundibulum with a grasper through the 5-mm trocar , moving the infundibulum right and left , back and forth to display the calot triangle . the cystic duct was then isolated , clipped and divided followed by the cystic artery . the gallbladder was dissected from the liver bed and subsequently extracted through the infraumbilical port . the patient had an uneventful recovery and was discharged home on the first postoperative day . since campos and sipes   described the first case of laparoscopic cholecystectomy in a patient with situs inversus , this uncommon malformation has been challenging and amazing many surgeons . due to the contralateral disposition of the viscera , the diagnosis and surgical approach of these patients may be more difficult than that of orthotopic patients . according to previous reports , however , the procedure often requires more time to rearrange the equipment in the operating room and extra care to recognize the mirror image anatomy . the anatomical variations and , mainly , the contralateral disposition of the biliary tree demand an accurate dissection and exposition of the biliary structures to avoid iatrogenic lesions . there is widespread acceptance that four - port technique is the standard procedure of traditional laparoscopic cholecystectomy . however , technical improvements have permitted the execution of less invasive procedures , using only three or even two ports to perform laparoscopic cholecystectomy . these modifications actually reduced postoperative pain , analgesia requirement , length of hospital stay and costs [ 7 , 8 ] . no other reports in the international literature were found describing the three - port technique in patients with sit , though . in our case , only three ports were necessary to perform a safe dissection and to obtain a good exposure of the gallbladder and the biliary tree . the dissection of the biliary tree can be carried out with either the right or the left hand , however for right - handed surgeons using the unskilled and nondominant left hand , the manipulation may be cumbersome and not precise . in the present case , the left - handed surgeon performed the dissection of the calot triangle by holding the dissecting instruments with the left hand through the 10-mm trocar and a grasper with the right hand to maneuver the gallbladder . the patient had a normal follow - up and , 5 months after surgery , remains asymptomatic . in conclusion , this case confirms that three - port laparoscopaic cholecystectomy is a safe and feasible surgical approach even in patients with sit presenting symptomatic cholelithiasis , despite the reverse anatomical relationships . however , to overcome technical difficulties and avoid iatrogenic lesions , the procedure must be carried out by an experienced laparoscopic surgeon , especially if the surgeon is left - handed , used to the three - port technique in orthotopic patients .
situs inversus totalis ( sit ) is an uncommon anomaly characterized by transposition of organs to the opposite side of the body in a mirror image of normal . 
 we report on an adult woman , born and resident in brazilian amazonia , presenting acute pain located at the left hypochondrium and epigastrium . during clinical and radiological evaluation , 
 the patient was found to have sit and multiple stones cholelithiasis . 
 laparoscopic cholecystectomy was safely performed with the three - port technique in a reverse fashion . in conclusion 
 , this case confirms that three - port laparoscopic cholecystectomy is a safe and feasible surgical approach to treat cholelithiasis even in rare and challenging conditions like sit .