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Difficulties in laparoscopic cholecystectomy 153Jurnalul de Chirurgie (Iaşi), 2013, Vol. 9, Nr. 2DISCUSSIONCreation of pneumoperitoneum is thefirst step of laparoscopic cholecystectomyand various difficulties can be seen at thisstep. In our study after analyzing theavailable literature we have found out theconditions which can make this step of LCdifficult. Out of 200 patients, there were 16patients who were anticipated to havedifficulty in creating a pneumoperitoneum.In this maximum anticipation was for thepatients who had previous abdominalsurgeries 8 (50%) and who were obese 7(43.5%). According to Underwood et al,intra abdominal adhesions secondary toprevious upper abdominal surgery can tetherunderlying viscera consequently increasesthe risk of hollow organ injury duringcreation of pneumoperitoneum by veressneedle and during placement of laparoscopictrocars [4]. A prospective study by M.Hussein et al [5] in obese patientsundergoing laparoscopic cholecystectomystated that only technical problem thatnecessitated conversion to operation wasfailure to establish a pneumoperitoneum.Once a pneumoperitoneum was established,each operation followed lines similar to LCin normal-size patients.Patients with acute cholecystitis haveoedema, hypervascularity, venousengorgement and gallbladder distension.Within 72 hours of symptoms the tissueplanes are oedematous and inflamed but areeasier to dissect, having no adhesions at all.But after 72 hours, the tissue becomes morefriable and becomes dangerous and risky todissect. Increased gall bladder wall thicknessis related to the inflammation and fibrosisthat follows attacks of cholecystitis and thusmay reflect difficulty in delineation of theanatomy during surgery. Problems withacute biliary pancreatitis are extensiveadhesions, visual road block due toinflammatory phlegmon in the region ofhead of pancreas, highly oedematous cysticpedicle and hepatoduodenal ligament, andpresence of ascitic fluid. Prior acutepancreatitis results in scarred and fibrosedgall bladder and in dense fibrotic adhesionsthat renders laparoscopic dissection difficult.[6,7]In our study out of 200 patients whounderwent laparoscopic cholecystectomy 22(11%) patients presented with acutecholecystitis after 72 hrs of onset ofsymptoms. Out of 70 difficult cases, therewere 54 (77.14%) patients who haddifficulty in separating adhesions. Maximumnumber of adhesions and difficultyseparating them was seen in patients withacute cholecystitis 22 (40.74%). Out of 70difficult cases, there were 4 (7.4%) patientswho had difficulty in separating adhesionsdue to pancreatitis.Out of 70 difficult cases there were 39(55.71%) cases in which skeletonization,ligation and division of cystic artery andduct was difficult. Maximum difficulty inthis step of LC was seen in patients withabnormal callot’s anatomy 20 (51.28 %). Ina study conducted by Ajay Anand et al [8]they found 17.61% patients in their studygroup who had wide cystic duct. K. Toresset al [9] in their study found that 37.6%patients had an atypical course of cysticartery. A randomised trial of laparoscopicversus open cholecystectomy for acute andgangrenous cholecystitis by Kiviluotoreported 16% patients in the LC grouprequiring conversion and in most casesbecause severe inflammation distorting theanatomy of Callot's triangle [10].Pawan Lal et al [11] in their study of73 patients found that 11 patients (15.07%)with contracted gallbladders, 8 laparoscopiccholecystectomies were surgically difficult,and 5 were converted to the open procedure.Patients with a small contracted gall bladderor a trabeculated gall bladder due to heavystone load and multiple criss cross stricturesin the gall bladder lumen, are also candidatesat risk where the surgeon would havedifficulty in holding the gall bladder [12]. Inour study there were 7 (3.5%) cases that hadsmall and contracted GB and 9 (4.5%) casesthat had intrahepatic GB, all of these caseswere difficult to operate upon. There were 4(2%) cases who had empyema GB but wereeasy to detach from the liver bed. A gall