Intraoperative difficulties in laparoscopic cholecystectomy

Introduction: Laparoscopic surgery has certain technical limitations like loss of three-dimensional perception, a relatively limited and fixed view of operative field, indirect contact with intraabdominal structures, and limited tactile feedback during dissection and manipulation of tissues. This makes operation difficult sometimes and leads to conversion to open cholecystectomy. AIM: The aim of the study was to study the intraoperative difficulties in Laparoscopic Cholecystectomy. Material and methods: This is a retrospective study from 2012-2017, a period of 5 years done in the Department of General Surgery at Government Medical College, Amritsar, Punjab, India. Difficult Laparoscopic Cholecystectomy was defined in those procedures which exceeded 90 minutes in duration and or converted to open procedure. Per operative difficulties were classified and studied in the following steps : 1) Creation of the pneumoperitoneum; 2) Separation of all adhesions; 3) Skeletonization, ligation and division of cystic artery and cystic duct; 4) Excision of Gall Bladder from the gall bladder fossa of the liver bed; 5) Extraction of Gall Bladder. RESULT: 200 patients who underwent Laparoscopic Cholecystectomy in the hospital from 2012to 2017 were included in this study. Out of 200 laparoscopic cholecystectomy (LC) 130 (65%) were easy and 70 (35%) were difficult. Out of these 70 difficult cases 12 (6%) required conversion to open cholecystectomy. The conversion rate was higher in the age group of > 60 years. The maximum difficulty occurred while separating the adhesions 75.71% out of 70 cases. Maximum difficulty while performing this step of LC was found in patients with Previous Abdominal Surgery 8 (50%). Maximum number of adhesions and difficulty separating them was seen in patients with acute cholecystitis 22 (41.50%). Out of 70 difficult cases there were 39 (55.71%) cases in which skeletonization, ligation and division of cystic artery and duct was difficult. Maximum difficulty in this step of LC was seen in patients with abnormal callot's anatomy 20 (51.28 %). Maximum conversion rate was seen with patients having abnormal callot's anatomy 35%. Conclusions: Previous abdominal surgery, intrahepatic gallbladder, multiple large calculi, very thick walled gallbladder, acute cholecystitis and abnormal callot's anatomy are the difficult factors to operate upon and increases the operating time. Acute cholecystitis and abnormal callot's anatomy are the two conditions in which the conversion rate is higher.