الفهرس 
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Abstract
This Current study was carried on 40 patients suffering from cholecystitis in Menoufiya University Hospitals (general surgery department) during the period from March 2016 to August 2017(18months) with follow up period from (6-12 months).All patients in this study were subjected to the following, History taking, routine laboratory investigations and abdominal ultrasound.
We assessed the procedure regarding :difficulties during accessing the peritoneal cavity, adhesions at the triangle of Calot, aberrant anatomy, gall bladder size, iatrogenic injuries, dissection of the gall bladder from its bed, extraction of the gall bladder, and conversion to open cholecystectomy also assessed technical difficulty of the operation by Cuschieri’s scale and identification of Calot’s node at each grade of difficulty and assessed relation of cystic artery to cystic lymph node in the study group. We resorted to the conventional four port technique (two 10 mm and two 5 mm ports) using the North American arrangement.
The aim of this study was to record different difficulties that may be encountered during laparoscopic cholecystectomy and how to manage this difficulties and identification of Calot lymph node and relation of cystic artery to Calot lymph node in the study group.
The intra operative difficulty which encountered during research was:
- Results according to Cuschieri’s scale difficulties were classified to:
Grade 1: 7 cases (17.5%), Grade 2: 19 cases (47.5%),
Grade 3: 11 cases (27.5%), Grade 4: 3 cases (7.5%).
Results about Identification of cystic lymph node in different grades of difficulty cleared that; Cystic lymph node was identified in 92.5 % of cases. Identified easily grade 1 and grade 2 and identified with difficulty in grade 3 after dissection of dense adhesions and not identified in 7.5% of cases. -Cystic lymph node was identified in 37 case of laparoscopic cholecystectomy; In 30 case (75%) cystic artery was posterior to LN and was lateral to LN in 7 cases (17.5%).
Acute cholecystitis: there were 5 cases of acute cholecystitis (12.50 %) with dense adhesions between the gall bladder and the surrounding structures adhesions were carefully released and the bleeding points meticulously hemostasis by diathermy and by using compression gauze. These five cases were approached within 72 hrs of the attack.
Aberrant anatomy in 2cases (5%); the right hepatic artery was evidently seen passing through the Calot’s triangle (caterpillar turn).
Adhesions at calot triangle ; that 5 cases with dense adhesions at Calot’s triangle (12.50 %); The anatomy of Calot’s triangle was not evident. skeletonization of the cystic pedicle by alternate use of diathermy (on the hook or Maryland), gauze piece and suction irrigation (hydro dissection) solved this problem.
Cholecystitis with liver cirrhosis in 2cases (5%); there were adhesions between the gall bladder and the surrounding structures, difficult liver retraction and oozing field. The bleeding profile and liver functions were adjusted pre-operatively. The body of the gall bladder was grasped for better retraction of the hard fibrotic liver.
Contracted fibrotic gall bladder in2 cases (5 %); Liver retraction and separation of the gall bladder from liver bed were difficult. A toothed grasper was used for grasping the fundus. The gall bladder was separated from the liver bed by alternate sharp and blunt dissection. There was a dense adhesion at callot triangle, either cystic lymph node or infundibulum can be identified so the two cases of fibrotic gallbladder was converted to open surgery and categorized as grade 4 difficulty.
Dense intraperitoneal adhesions there were 8 cases with intra-abdominal adhesions (20 %); there were dense adhesions between the gall bladder and omentum, duodenum and anterior parietal peritoneum. The inferior margin of the liver acted as an initial land mark for identifying the gall bladder. Alternate sharp and blunt dissection close to the liver margin exposed the fundus which was elevated to induce counter traction and release the rest of adhesions till the neck of the gall bladder.
3 cases were converted to open cholecystectomy (7.5 %) The causes of conversion were as follows:
One case: dense adhesions and inability to identify the cystic pedicle.
Two cases: dense adhesions, fibrotic gall bladder.