The difficult gallbladder is the most 'difficult ...



The difficult gallbladder is the most "difficult" laparoscopic surgery being performed by general surgeons all over the world and the potential one that places the patient at significant risk.

• Factors affecting the conversion completion rate of lap chole

• Patient having absolute contraindications to lap chole like

* cardiovascular and pulmonary disease

* conversion had to be done due to several reasons

- low in experienced hands

Difficult in

1. Acute cholecystitis with clinical (right upper abdominal quadrant pain with positive Murphy's sign and few). CBC Leucocytosis

2. Empyema and instrumental evidence (US signs of increase of the thickness of the gallbladder wall, presence of pericholecystic fluid

3. Gangrenous gallbladder

4. Perforation

5. Cirrhotic patients (hepatic cirrhosis material)

6. Mirizzi syndrome

7. The anatomic variations

8. Portal hypertension and obesity, because of the adiposity of the hepato-duodenal ligament and so a greater difficulty in the recognition of the structures in the Calot's triangle

9. Intraoperative complications that are absolutely unpredictable, e.g. bleeding

10. Male gender (intrahepatic gallbladder). A gallbladder may congenitally be partially or completely embedded in the liver parenchyma

11. Common bile duct stones or may become buried ducts recurrent episodes of inflammation

12. Coagulopathy which need correction prior to cholelystectomy

13. Porcelain gallbladder, calcification of gallbladder wall

14. A large calcified gallstone

15. En emphysematous cholecystitis or aerobilia due to cholecysto-enteric fistula relatively contraindicates laparoscopic surgery.

16. Pregnancy patient

17. Gallbladder cancer

18. Haemangioma near or at the gallbladder fossa.

Definition of difficult cholecystectomy

1. dense adhesion at the triangle of calot and unclear anatomy (frozen triangle of calot prohibiting proceeding laparoscopy without risk)

2. contracted and fibrotic gallbladder

3. previous abdominal surgery

4. gangrenous gallbladder

5. acutely inflamed gallbladder

6. empyema gallbladder (including Mirrizi syndrome Type II)

7. cholecysto-gastric or cholecystoduodenal fistula

8. accessory cystic duct (Strassberg Type A)

9. The anatomic variations

Solution:

1. Placing additional trocars to facilitate liver and duodenal retraction

2. Aspirating the gallbladder through the 5 mm subcostal trocar or using a 10 mm toothed grasper for grasping

3. Placing verress needle at site far away from previous scar or by open Hassan technique

Thick-walled gallbladders

• In cases with acute inflammation of the gallbladder a peanut swab held in a grasper used for blunt dissection allowed planes to be opened up with greater ease and safety.

• Aspiration of the distended gallbladder allows confirming the diagnosis and at the same time makes the handling of the gallbladder easier during the subsequent dissection.

The problem relating to this abnormality is an inability to grasp the fundus of the gallbladder and an absence of avascular plane of dissection between the gallbladder and liver parenchyma which makes it technically a challenging task.

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