الفهرس 
Aim of theWorkOnly 14 pages are availabe for public view
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Abstract
Laparoscopic cholecystectomy has replaced open
cholecystectomy as the therapeutic modality in the treatment of
symptomatic gallstones. Laparoscopic cholecystectomy (LC) may be
rendered ’difficult’ by various problems encountered during surgery.
Substantial proportions of patients in whom LC cannot be successfully
performed are converted to open cholecystectomy. Conversion to
laparotomy is indicated whenever the key technical points of the
procedure are not possible. The clinical profile of the patient can
predict difficult LC. This information can be useful to both the patient
and the treating surgeon.
The present study was carried out on 100 patients with
symptomatic cholelithiasis admitted to the Department of Surgery
Faculty of Medicine, Menoufia University and Tala General Hospital
from January 2018 to march 2019.Excluding cases of patient
contraindication to lap chole cardiac and respiratory, pregnancy, cases
with bile duct stones, and cases with history of upper abdominal
operations.
Aim of this study was to evaluate the pre-operative factors
associated with difficult laparoscopic cholecystectomy.
They were 73 females and 27 males. The mean age was 48.2 ±
12.5 years. Fifty eight patients were obese with mean Body Mass
Index of 29.9 ± 5.3kg/m2.
Detailed history, physical examination, routine and specific
laboratory investigations and ultra-sonography were done to all
patients.
Summary
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Parameters of prediction of difficult cholecystectomy in our
study were based on the clinical criteria of:
The patient‟s characteristics: gender, age and body habits.
The patient‟s history: jaundice, previous acute attacks of
cholecystitis and previous abdominal surgery.
The presence of local signs of cholecystitis especially palpable
GB.
The findings in ultrasonography: shape of the GB, number and
size of stones and liver parenchyma.
There were 6 patients with history of jaundice (6%), 16 patients
with history of acute attacks of cholecystitis (16%), and 14 patients
had history of lower abdominal operations (14%).
Clinical examination revealed positive Murphy’s sign in 16
patients (16%), and palpable GB in 6 of them (6%).
Abdominal ultra-sonographic examination revealed that 74
patients had multiple small stones (74%), and 26 patients had solitary
large stone (26%).
7 patients had distended gallbladders (7%) and 93 had average
size gallbladders (93%).
Gall bladder showed normal wall thickening in 97 (97%) patients
while thick wall was seen in 3 patients (3%).
Common bile duct diameter was within the normal range in all
patients, with no stones inside.
Summary
66
All cases underwent laparoscopic cholecystectomy with
assessment of the difficulties encountered in terms of:
1. Duration of surgery (in minutes): Duration of surgery including
the time from insertion of visiport to closure of the trocar
insertion site.
2. Bleeding during surgery: graded as minimal, moderate or severe.
Moderate bleeding was defined as bleeding leading to
tachycardia of greater than 100 b/min without DROP in blood
pressure. Severe bleeding was defined as bleeding leading to
tachycardia of greater than 100 b/min with a greater than 10
mmHg DROP in blood pressure.
3. Access to peritoneal cavity: easy or difficult as described by the
operating surgeon.
4. Gall bladder bed dissection: easy or difficult as described by the
operating surgeon.
5. Extraction of gall bladder: easy or difficult as described by the
operating surgeon.
6. Conversion to open cholecystectomy (OC) if done.
Laparoscopic cholecystectomy was successfully accomplished in
97 patients (97%) with a mean operative time of 52.9 ± 18.8 minutes.
Access difficulties occurred in 5 cases (5%); due to obesity and
previous attacks of cholecystitis. Extensive adhesions occurred in 30
cases (30%); due to previous cholecystitis.
Summary
67
Minimal bleeding occurred in 8 patients (8%) from the liver bed
during GB bed dissection and was successfully controlled by electrocautery
coagulation.
Gall bladder bed dissection was difficult in 12 cases (12%) due to
thick gall bladder wall, previous acute cholecystitis and liver fibrosis.
Gall bladder perforation occurred in 18 cases (18%) while stone
spillage occurred in 2 cases (2%) and were all retrieved.
Extraction of the excised gall bladder was difficult in 17 cases
mainly due to the large size of the stones (17%). Conversion to
laparotomy occurred in 3 cases (3%) due to dense adhesions at Calot‟s
triangle (one cases), Mirrizi‟s syndrome (one cases), and uncontrolled
bleeding (one cases).