Article Type

Original Study


Objective The aim of the study was to record different difficulties during laparoscopic cholecystectomy and how to manage with special respect to the preoperative detection of these difficulties. Background «SQ»Difficult«SQ» is a relative term but generally difficult cholecystectomies include difficult peritoneal access due to morbid obesity or previous abdominal surgery, intra-abdominal adhesions, acute cholecystitis, liver cirrhosis, gall bladder mucocele, contracted gall bladder, frozen Calot«SQ»s triangle, floppy left lobe of the liver, and aberrant anatomy. Patients and methods Fifty patients of difficult laparoscopic cholecystectomies were recorded over a period of about 18 months; most of them were preoperatively expected to be difficult and most of these difficulties were overcome by means of laparoscopic techniques. Results Laparoscopic cholecystectomy was successfully accomplished in 47 patients (94%) with a mean operative time of 52.6 ± 18.66 min. Three patients were converted to open cholecystectomy (6%), in two patients due to dense adhesions with the gall bladder and in one patient due to iatrogenic injury to the cystic duct during skeletonization of frozen Calot«SQ»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 greater than 5 mm (based on ultrasound). Conclusion Low conversion rate was attributed to adequate vision, minimal use of electrocautery at the triangle of Calot, displaying the structures at the triangle of Calot before clipping, adequate traction in proper direction, use of gauze dissection and hydrodissection in difficult patients and reconfirming the anatomy from time to time.