الفهرس 
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Abstract
The present study was carried out on 50 patients with symptomatic
cholelithiasis admitted to Menoufiya University Hospitals(general
surgery department) and Gamal Abdel_Naser Health Insurance Hospital
in Alexandria excluding pregnant females, cases with gall bladder cancer,
and concomitant choledocholithiasis.
The aim of this study was to record different difficulties that may be
encountered during laparoscopic cholecystectomy and how to manage
these difficulties with special respect to the pre-operative detection of
these difficulties in order to minimize both morbidity and mortality.
The patients were 42 females and 8 males and the age of the patients
ranged from 25-65 years with a mean of 46.6±11.6, the most frequent age
group was 41-50 years with 17 patients (34.0%), while the lower frequent
age group was 61-65 years with percent of 6.0%. The duration of the
disease ranged from 3 - 22 months with a mean of 14.65±8.98 month, the
most frequent duration group was 12-18 months with percent of 42.0%.
History of acute cholecystitis was found in 17 cases (34.0%), 5 of them
presented and underwent surgery in the first 72 hrs.
There were 11 cases with previous abdominal surgery, 6 of them had
appendectomy (12.0%) and 5 cases with caesarian section (10.0%).
There was history of jaundice in 5 cases, In 2 cases the jaundice resolved
spontaneously and the remaining 3 cases underwent ERCP,
sphincterotomy and stone retrieval. the BMI ranged from 21.3-42.7
kg/m2 with a mean of 32.68±5.69.
Clinical examination revealed that 12 patients had tenderness at right
hypochondrium, 6 patients had positive Murphy’s sign and 3 patients had
palpable gall bladder.
Abdominal U/S showed that 24 patients (48.0%) had fatty
infiltration, while 8 cases showed cirrhosis, the other 18 cases had normal
liver. Gall bladder was contracted in 4 cases (8.0%) and distended in 7
cases (14.0%). Gall bladder wall thickening was found in 19 cases
(38.0%), 13 of them less than 5 mm and 6 cases more than 5 mm.
Common bile duct diameter was within the normal range in all patients,
with no stones inside.
Laparoscopic cholecystectomy was successfully accomplished in 47
patients (94%) with a mean operative time of 52.6±18.66 minutes. Three
cases were converted to open cholecystectomy (6.0 %); in 2cases due to
dense adhesions with the gall bladder and in one case due to iatrogenic
injury to the cystic duct during skeletonization of frozen Calot’s triangle.
Our most common intraoperative pathology was dense
intraperitoneal adhesions between the gall bladder and the surrounding
structures (28 %). The second most common intraoperative pathology
was cirrhotic liver (16 %).
The preoperative parameters that significantly predicted difficult
laparoscopic cholecystectomy were previous acute attacks of cholecystitis
and long duration of the disease, local signs of acute cholecystitis,
obesity, contracted gall bladder, gall bladder with large stones and
increased gall bladder wall thickness > 5 mm (based on U/S).