Difficult Cholecystectomy Research Articles

Laparoscopic subtotal cholecystectomy: a safe approach in difficult cholecystectomy

Background: Laparoscopic cholecystectomy (LC) has been recognized as the new "gold standard" for the treatment of symptomatic gallstone disease. In order to prevent serious bile duct and vascular injuries, conversion is advocated for unclear anatomy at the Calot’s. Our aim was to assess the safety and effectiveness of laparoscopic subtotal cholecystectomy (LSC) in difficult cholecystectomy in order to reduce the incidence of bile duct injury and conversion rates.Methods: An analysis of retrospectively collected data of 452 patients who underwent LC was done at our Hospital during the period of January 2010 to December 2013. In few cases of difficult GB when Calot’s could not be dissected, laparoscopic retrograde cholecystectomy (LRC) was attempted and if that failed we adopted the technique of LSC.Results: A total of 452 patients were included. The median age was 48 years. All the 452 patients were posted for LC. Of the 452 patients, 404 patients underwent LC and the remaining 48 patients had difficult GB. Among the 48 patients having a difficult GB, 44 cases underwent LSC (3 cases underwent LSC Type-1 and 41 cases underwent LSC Type-2) and the remaining 4 cases underwent conversion to open cholecystectomy. The mean operative time was 130mins and median post op stay was 2 days.Conclusions: In our technique of LSC the conversion rates were <1% with no bile duct injury and believe that it is feasible and safe for operating on difficult GB’s.

Commentary on: Feasibility and Value of the Critical View of Safety in Difficult Cholecystectomies.

Commentary on: Feasibility and Value of the Critical View of Safety in Difficult Cholecystectomies.

Effect of Duration of Calot’s Triangle Dissection on the Definition of Difficult Cholecystectomy

Effect of Duration of Calot’s Triangle Dissection on the Definition of Difficult Cholecystectomy

Biliary mapping using indocyanine green dye during laparoscopic cholescystectomy

Introduction: Although indocyanine green dye studies have been published earlier,the majority of the studies published to date actually excluded patients with - Acute cholecystitis,biliary pancreatitis,cholangitis,Common bile duct stones Method: This study is a prospective observational study.Patients undergoing laparoscopic cholecystectomy are given ICG dye 30mts before surgery and biliary structures are visualised immediately at surgery, after calots dissection using NIR camera and reported Result: Sample size – 199; Duration of study - 2 years GALL BLADDER PATHOLOGY SYMPTOMATIC GALL STONE DISEASE -1O5; ACUTE CHOLESCYSTITIS – 44; CHRONIC CHELSCYSTITIS -16; GALL BLADDER POLYP – 2; BILIARY PANCREATITIS- 9; MUCOCELE GB -6; EMPYEMA GB – 2; PERFORATED GB - 4 ; GANGRENOUS GB - 11 VISUALISATION OF EXTRA HEPATIC STRUCTURES CYSTIC DUCT- 168; CHD -165; CBD -182; CONFLENCE - 172 VISUALISATION OF CYSTIC DUCT ,CHD AND CBD IN DIFFICULT CHOLECYSTECTOMIES IN PERCENTAGES CHRONIC CHOLECYSTITIS- 68.8,81.2,81.2; ACUTE CHOLECYSTITIS- 70.5,84.5,84.5; BILIARY PANCREATITIS - 88.9,88.9,88.9; MUCOCELE- 83.3,83.3,83.3; EMPYEMA- 100,100,100; PERFORATION - 75,25,75; GANGRENE-18.2 ,27.3,27.3. The above data shows that extrahepatic structures can be visualised even in difficult cholecystectomies in more than 75 % of cases barring gangrenous gallbaldder. Conclusion: 1.Fluorescence cholangiography helps in identifying the extrahepatic biliary structures in majority of the patients.2.Within BMI<35kg/m2 higher BMI is not a deterrent to visualization of anatomy with NIRC. 3.With rising severity of inflammation the visualization of extra-hepatic biliary structures using ICG dye with NIRC are getting obscured. 4 .Variations in the cystic duct can be identified. 5.Fluorescent cholangiogram showed a 2 fold increase in identification of biliary anatomy after dissection of Calot’s.

The first experience of fluorescence laparoscopy for cholecystectomy, the bile ducts and the colon surgery

The aim — to analyse of the first experience with the use of fluorescence laparoscopy (FL) in technically difficult cholecystectomies, revision of the choledochus, lymphodection, colon resection and to assess the blood supply of the anastomosis sites.Materials and methods. Fluorescence laparoscopy was applied in 7 cholecystectomies for acute calculous cholecystitis, 6 common bile duct laparoscopic revisions to estimate the patency (first‑time used technique), laparoscopic right‑side hemicolectomy for estimation the blood supply of anastomosing intestinal areas and open resection of the transverse colon during limfodissections.Results and discussion. In cholecystectomies (fluorescence cholangiography), the duration of the operation and the average time to achieve a «critical type of safety» were reduced to 30 minutes compared with the comparison group (45 minutes). During the intraoperative revision of the choledochus in 1 case of fluorescence in the duodenum was not detected, which showed its obstruction (calculus inclusions). In other cases, the choledochal patency was preserved, which was associated with transient choledocholithiasis. With right‑sided hemicolectomy by fluorescent angiography, adequate blood supply to the colon stump has been proven. With open resection of the transverse colon, fluorescence lymphography was successfully used to visualize the apical lymph nodes at the mouth of the middle colon artery.Conclusions. The first experience showed that fluorescence laparoscopy allows to facilitate and accelerate dissection in case of technically difficult cholecystectomies, to assess the passage of the common bile duct in distinct cases (for example, transient choledocholithiasis), to evaluate the blood supply of the anastomotic sites in colon resections, and to monitor the adequacy of lymph node dissection.

Predicting a ‘difficult cholecystectomy’ after mild gallstone pancreatitis

BackgroundCholecystectomy after gallstone pancreatitis may be technically demanding. The aim of this study was to investigate risk factors for a difficult cholecystectomy after mild pancreatitis. MethodsThis was a prospective study within a randomized controlled trial on the timing of cholecystectomy after mild gallstone pancreatitis. Difficulty of cholecystectomy was scored on a 0 to 10 visual analogue scale (VAS) by the senior attending surgeon. The primary outcome ‘difficult cholecystectomy’ was defined by presence of one or more of the following features: a VAS score ≥ 8, duration of surgery > 75 minutes, conversion or subtotal cholecystectomy. Results249 patients were included in the primary analysis. A difficult cholecystectomy occurred in 82 patients (33%). In the ‘same-admission cholecystectomy’ group 29 of 112 cholecystectomies were difficult (26%) versus 49 of 127 patients (39%) who underwent surgery after 2 weeks (p = 0.037). After multivariable analysis, male sex (OR 1.80, 95% confidence interval [CI] 1.04−3.13; p = 0.037), prior sphincterotomy (OR 1.79, 95% CI 1.01−3.16; p = 0.046), and delaying cholecystectomy for at least two weeks (OR 1.81, 95% CI 1.04−3.16; p = 0.036) were independent predictors of a difficult cholecystectomy. ConclusionSurgeons should anticipate a difficult cholecystectomy after mild gallstone pancreatitis in case of male sex, prior sphincterotomy and delayed cholecystectomy.

A new clinical-ultrasound score to predict difficult videolaparocholecystectomies: A prospective study.

BackgroundThe gold standard treatment of symptomatic cholelithiasis is videolaparoscopic cholecystectomy (VLC). The aim of this study is to produce a predictive clinical ultrasound (US) score for difficult VLC to reduce the rate of conversion to open cholecystectomy surgery and intra and/or post-operative complications.MethodsIn this prospective study carried out in 2017 we enrolled 135 patients (pts) who underwent VLC in our General Surgery Unit. A specific pre-operative abdominal ultrasound scan was performed to assess gallbladder characteristics for each patient. All US and patients' characteristics were recorded in a standard form in order to obtain a preoperative score and were then added to the intra-operative variables.ResultsThe analysis revealed a statistical significance between post-operative characteristics and parietal thickness, adhesions, stratifications and volume of gallstones. Comparing the degree of difficulty VLC assessed in the pre-operative stage to the intraoperative score, the sensitivity of the preoperative US scan test is 91.8% while the specificity is 76.7%.ConclusionsThe variables which proved statistically significant in predicting a difficult cholecystectomy were: age, parietal thickness >3 mm, adhesions, stratifications, gallstones >2 cm and fixed gallstones. We have definitively defined a predictive score for difficult VLC for which a VLC is to be considered potentially difficult whenever it presents a pre-operative score equal or greater than 4 (and a "easy" one with a pre-operative score less than 4). These findings may prove helpful in further reducing the conversion rate and the rate of intra- and/or post-operative complications.

Routine versus difficult cholecystectomy: using predictive analytics to assess patient outcomes

BackgroundThe American College of Surgeons National Surgical Quality Improvement Program® (NSQIP) Surgical Risk. Calculator (SRC) estimates postoperative outcomes. The aim of this study was to develop and validate a specific predictive outcomes model for cholecystectomy procedures. MethodsPatients who underwent cholecystectomy between 2008 and 2016 and were deemed too high risk for acute care general surgery (GS) and had surgery performed by the Division of Hepatopancreatobiliary Surgery (HPB) were identified. Outcomes of the HPB cholecystectomies were matched against cholecystectomies performed by GS. New predictive models for postoperative outcomes were constructed. Area under the curve was used to assess predictive accuracy for both models and internal validation was performed using bootstrap logistic regression. ResultsA total of 169/934 (18%) cholecystectomies were identified as too high risk for GS. These 169 patients were matched with 126 patients who had cholecystectomy performed by GS. For GS and HPB cholecystectomies, the proposed model demonstrated better discriminative ability compared to the SRC based on ROC curves (proposed model: 0.589–0.982; SRC: 0.570–0.836) for each of the predicted outcomes. ConclusionFor patients undergoing cholecystectomy, customized models are superior for predicting individual perioperative risk and allow more accurate, patient-specific delivery of care.

The role of C-reactive protein as a predictor of difficult laparoscopic cholecystectomy or its conversion

Background: Laparoscopic cholecystectomy (LC) can be the easiest or the most difficult laparoscopic operation. Conversion to open surgery has been a traditional marker of difficult LC. Recent studies have shown that C-reactive protein (CRP) may be helpful to surgeon in knowing the pathological condition of gall bladder before removal. Aim of this study was to evaluate the role of CRP as a predictor of difficult LC or its conversion.Methods: This study was done from 1 march 2016 to may 2017 in department of general surgery, SMS hospital Jaipur, under single unit. All patients with cholelithiasis admitted in single unit of SMS hospital undergoing LC were included in this study. Exclusion criteria were high BMI (&gt;35), proven congenital anomaly of gall bladder, previous abdominal surgery, any conditions increasing CRP and immunocompromised patients. CRP was done for each patient.Results: Mean age of our 148 patients was 50.41 years. Female to male ratio was 4.28:1. Mean CRP was 22.2±18.2 mg/dl for simple cholecystectomy, 46.5±32.0 mg/dl for difficult cholecystectomy and 83.6±22.4 mg/dl for laparoscopic converted to open cholecystectomy, which was statistically significant (p value 0.0002).Conclusions: CRP is a potent predictor of difficult laparoscopic cholecystectomy and its conversion preoperatively. Patients with preoperatively high CRP have higher chance of complication intraoperative and high chances of conversion to open.

Role of gallbladder wall thickness in predicting laparoscopic operability prior to cholecystectomy: a retrospective analysis

Background: Laparoscopic cholecystectomy is the gold standard procedure for cholecystitis. There are variable rates of conversion of laparoscopic cholecystectomy to open cholecystectomy. Various studies have highlighted gall bladder wall thickness of &gt; 3mm as an independent risk factor for conversion. The purpose of our study is to predict the feasibility of cholecystectomy laparoscopically bases on the pre-operative ultrasound guided measurement of gall bladder wall thickness.Methods: It is a retrospective study conducted in the Department of Surgery, Himalayan Institute of Medical Sciences (HIMS) from June 2016 to September 2017. Patient’s pre-operative complete haemogram, liver function tests were also analyzed. Gallbladder wall thickness was estimated by using the maximal obtainable measurement at the fundus. A thin gallbladder wall was less than 3 mm in diameter. A thick gallbladder wall was 3 mm or greater in diameter.Results: A total of 192 patients were included in this study. Most of the patients were of the age group between 30-40 years, with average age of 37 years and 70% of the patients were females. Out of 192, 176 patients underwent laparoscopic cholecystectomy and 16 patients required conversion to open surgery. Ninety patients (46.8%) had cholecystectomy for acute cholecystitis and one hundred two patients (53.15%) had cholecystectomy for chronic cholecystitis. The gallbladder wall was found to be greater than 3 mm in 23 patients (25.5%) with acute calculous cholecystitis and greater than 3 mm in 25 patients (24.5%) with chronic calculous cholecystitis. Forty-eight patients, out of a total of 192, had a gallbladder wall thickness greater than 3 mm by preoperative sonography and 16 of these patients (33.3%) required conversion to an open cholecystectomy.Conclusions: Gall bladder wall thickness bases on ultrasound is a good predictor for difficult cholecystectomy and conversion to open surgery.

A Rare Pathology of Difficult Laparoscopic Cholecystectomy: Xanthogranulomatous Cholecystitis.

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory condition of the gallbladder (GB). Preoperatively, it is a diagnostic challenge. One thousand and seventy nine laparoscopic cholecystectomy (LC) patients from September 2012 to June 2015 were retrospectively reviewed. Fourteen patients were identified with XGC. An analysis was carried out on this group of patients looking at postoperative pathology results, preoperative radiology, operative findings and outcome. The overall frequency of XGC was 1.3%. A thick walled GB was found in 11 patients on preoperative imaging. Retrospectively suggestive feature thick gallbladder walls with low attenuation mural nodules. No suspicion of cancer was demonstrated in the final histology or preoperatively. Five cases (36%) perforated intraoperatively. Although all were surgically challenging, no conversions to open were performed. The perforation risk could be higher. A difficult cholecystectomy should alert a surgeon to consider XGC as a diagnosis. Contrary to the popular belief, XGC was found to be difficult to differentiate from infection rather than malignancy.

Acute cholecystitis: comparing clinical outcomes with TG13 severity and intended laparoscopic versus open cholecystectomy in difficult operative cases.

The revised Tokyo Guidelines include criteria for determining the severity of acute cholecystitis with treatment algorithms based on severity. The aim of this study was to investigate the relationship of the revised Tokyo Guidelines severity grade to clinical outcomes of cholecystectomy for acute cholecystitis. We identified 66 patients with acute cholecystitis from a prior study of difficult cholecystectomy cases. We examined the relationship between severity grade and multiple variables related to perioperative and postoperative outcomes. A more severe revised Tokyo Guidelines grade was associated with a higher number of complications (p = 0.03) and a higher severity of complications (p = 0.01). Severity grade did not predict operative time, estimated blood loss, intensive care unit admission or length of stay. Compared to planned open cholecystectomy, intended laparoscopic cholecystectomy was associated with significantly fewer total and Clavien-Dindo grade 3 complications, fewer intensive care unit admissions, and shorter length of stay (p values range from 0.03 to < 0.0001). In technically difficult operations for acute cholecystitis, the revised Tokyo guidelines severity grade correlates with the number and severity of complications. However, intended performance of laparoscopic cholecystectomy rather than open cholecystectomy in difficult operations predicts broader beneficial outcomes than severity grade.

Intra-Operative Predictors of difficult cholecystectomy and Conversion to Open Cholecystectomy - A New Scoring System.

Objective:To evaluate the intra-operative scoring system to predict difficult cholecystectomy and conversion to open surgery.Methods:This descriptive study was conducted from March 2016 to August, 2016 in the Department of Surgery, Shalimar Hospital. The study recruited 120 patients of either gender, age greater than 18 years and indicated for laparoscopic cholecystectomy (LC). Intra-operatively all patients were evaluated using the new scoring system. The scoring system included five aspects; appearance and adhesion of Gall Bladder (GB), distension or contracture degree of GB, ease in access, local or septic complications, and time required for cystic artery and duct identification. The scoring system ranges from 0 to 10, classified as score of <2 being considered easy, 2 to 4 moderate, 5–7 very difficult, and 8 to 10, extreme. Patient demographic data (i.e. age, gender), co-morbidities, intra-operative scores using the scoring system and conversion to open were recorded. The data was analysed using statistical analysis software SPSS (IBM).Results:Among one hundred and twenty participants, sixty seven percent were females and the mean age (years) was 43.05 ± 14.16. Co-morbidities were present in twenty percent patients with eleven diagnosed with diabetes, six with hypertension and five with both hypertension and diabetes. The conversion rate to open surgery was 6.7%. The overall mean intra-operative scores were 3.52 ± 2.23; however significant difference was seen in mean operative score of converted to open and those not converted to open (8.00 ± 0.92 Vs. 3.20 V 1.92; p-value = 0.001). Among eight cases converted to open, three (37.5%) were in very difficult category while five (62.5%) were in extreme category. Moreover, age greater than 40 years and being diabetic were also the risk factors for conversion to open surgery.Conclusion:The new intra-operative scoring system is a valuable assessment tool to predict difficult laparoscopic cholecystectomy and conversion parameters to open surgery and its utility could improve patient's clinical outcome indicated for laparoscopic cholecystectomy.

A Prospective study of Role of Magnetic Resonance Cholangiopancreatography for Prediction of Difficult Cholecystectomy

A Prospective study of Role of Magnetic Resonance Cholangiopancreatography for Prediction of Difficult Cholecystectomy

A comparative study of laparoscopic versus mini laparotomy cholecystectomy

Background: Gallstones are common in Indian population and its treatment has shown a decisive shift from open to minimally invasive route. There is no doubt that laparoscopy require longer and steeper learning curve and higher cost, especially in the absence of health insurance to majority of suburban and rural Indian population. However, preferences of patients are changing rapidly due to better level of awareness and availability of healthcare facility. Aims was to study safety and efficacy of laparoscopic cholecystectomy in patients of cholelithiasis by comparing withresults of mini laparotomy cholecystectomy by comparing use of post-operative analgesia, operative Time, post-operative hospital stay, morbidity and mortality.Methods: It is a prospective randomized study of 100 Patients of cholelithiasis aged between 25 years to 65 years operated during 2016-2017 at Dr. D Y Patil medical college Pune. They were divided into mini laparotomy and laparoscopic cholecystectomy group by draw a lot method. Patient’s written valid informed consent for the particular procedure was taken and the pros and cons of both the procedure were explained in detail to the patient. This study was done after due clearance of ethical committee.Results: The median (range) operation time for laparoscopic cholecystectomy was 50-175 min (mean=103.98 min) and 35-95 min (mean=70 min) for mini laparotomy cholecystectomy (p&lt;0.001). During the study period operation time for laparoscopic cholecystectomy showed a tendency to become shorter. The use of Injectable analgesics in case of laparoscopic cholecystectomy (Mean no. of days=1.5) is considerably less than mini laparotomy cholecystectomy (Mean no. of days=3.36). Conversion rate in literature in laparoscopic cholecystectomy ranges from 3% to 15% in well trained hands. In our series it is 6% in spite of being a teaching and training institution.Conclusions: Minimally invasive surgery is better than mini laparotomy cholecystectomy in terms of post-operative pain, analgesic requirement and early return to work. However, mini laparotomy cholecystectomy is preferred method for Surgeons in the beginning of their career and in case of difficult cholecystectomy.

Preoperative Prediction of a Difficult Cholecystectomy: Not That Difficult?

Santos, Jeffrey W.; Sarkar, Bedabrata MD, PhD, FACS; Brahmbhatt, Tejal S. MD; Sanchez, Sabrina MD; Burke, Peter A. MD, FACS; LeBedis, Christina MD; Gupta, Avneesh MD; Kasotakis, George MD, MPH Author Information

ASSESSMENT OF FEASIBILITY AND COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY IN CIRRHOTIC PATIENTS

Abstract :Introduction: From the era of absolute contraindication to the phase of preferred treatment, the technique of laparoscopic cholecystectomy advances with time. Here, we report our experience of laparoscopic cholecystectomy in 20 patients of liver cirrhosis. In our institute, laparoscopic cholecystectomy is the preferred choice for cholelithiasis in cirrhotic patient.Methods: In last 2 years, 180 laparoscopic cholecystectomies were performed and 20 patients were cirrhotic. Their data analyzed retrospectively in terms of preoperative optimization, operative technique and results.Results: Laparoscopic cholecystectomy was completed successfully in 19 patients and one was converted to open. Mean operative time was 54 minutes. No additional port was required in all cases. Calot’s first dissection was performed in 18 patients and fundus first technique was used in 2 patients due to unclear anatomy. Liver bed bleeding was present in 16 patients, which was controlled effectively. Subhepatic drain was placed in 12 patients. There was no mortality. Morbidity in two patients was worsening of ascites in one; and incisional hernia in other patient which was converted to open. Port site complications were not noted in any patient and there was no evidence of intraabdominal bleeding or bile leak postoperatively. Blood and component transfusion was required in 2 patients. Average length of hospital stay was 4.8 days.Conclusion: Though laparoscopic cholecystectomy may be difficult in cirrhotic patients but it is feasible and relatively safe. It offers many advantages in cirrhotic patients and associated with low morbidity when compared with open surgery.Keywords: cirrhosis, laparoscopic cholecystectomy, difficult cholecystectomy

Optimal timing of cholecystectomy after percutaneous gallbladder drainage for severe cholecystitis

BackgroundThe Tokyo guideline for acute cholecystitis recommended percutaneous transhepatic gallbladder drainage followed by cholecystectomy for severe acute cholecystitis, but the optimal timing for the subsequent cholecystectomy remains controversial.MethodsSixty-seven patients who underwent either laparoscopic or open cholecystectomy after percutaneous transhepatic gallbladder drainage for severe acute cholecystitis were enrolled and divided into difficult cholecystectomy (group A) and non-difficult cholecystectomy (group B). Patients who had one of these conditions were placed in group A: 1) conversion from laparoscopic to open cholecystectomy; 2) subtotal cholecystectomy and/or mucoclasis; 3) necrotizing cholecystitis or pericholecystic abscess formation; 4) tight adhesions around the gallbladder neck; and 5) unsuccessfully treated using PTGBD. Preoperative characteristics and postoperative outcomes were analyzed.ResultsThe interval between percutaneous transhepatic gallbladder drainage and cholecystectomy in Group B was longer than that in Group A (631 h vs. 325 h; p = 0.031). Postoperative complications occurred more frequently when the interval was less than 216 h compared to when it was more than 216 h (35.7 vs. 7.6%; p = 0.006).ConclusionsCholecystectomy for severe acute cholecystitis was technically difficult when performed within 216 h after percutaneous transhepatic gallbladder drainage.

Subtotal laparoscopic cholecystectomy influences the rate of conversion in patients with difficult laparoscopic cholecystectomy: Case series.

ObjectivesThis study aimed to show that subtotal laparoscopic cholecystectomy (SLC) is a safe procedure that reduces the rate of conversion in patients with difficult laporoscopic cholecystectomies in resource-meagre settings.Patients and methodsFollowing informed consent, patients with gallstones reporting to Atbara Medical Centre, Atbara, Northern Sudan from February 2012 to July 2013 were managed laparoscopically except those with choledocholithiasis. SLC was done for patients with difficult cholecystectomy and obscured Callot's triangle. Clinical presentation, duration of symptoms, ultrasound findings, frequency of conversion to open operation, frequency of difficult cholecystectomy, operation duration and numbers/types of complications were recorded. Statistical analysis was carried out using SPSS.ResultsOne hundred and nine patients with a median age of 48 years, F:M ratio of 9 and mean duration of symptoms of 14.8 ± 12.9 months were enrolled. A quarter (29/109, 26.6%) had acute choleycystitis, 13% had difficult laparoscopic cholecystectomy. SLC was done for 16.2%. Retained stones were statistically significant in patients who underwent subtotal laparoscopic cholecystectomy (p = 0.02) with a conversion rate of 5.5%.ConclusionSLC is feasible, safe and can reduce the rate of conversion for patients with difficult laporoscopic cholecystectomy. Sub-total laparoscopic cholecystectomy is not a substitute to conversion and in difficult conditions it is not a failure for the surgeon but a wisdom.

Retroinfundibular laparoscopic cholecystectomy versus standard laparoscopic cholecystectomy in difficult cases

BackgroundLaparoscopic cholecystectomy becomes the gold standard surgical procedure for treating gallstones. Standard laparoscopic cholecystectomy (SLC) requires proper dissection of Calot's triangle to achieve the critical view of safety. This may be difficult in certain conditions, resulting in higher incidence of bile duct injury and conversion to open. We aimed to compare the outcomes of laparoscopic cholecystectomy by retroinfundibular (RI) approach to that of SLC, in difficult cases. Patients and methodsThis study is prospective cohort study, in which 60 patients were operated by SLC and 65 patients by laparoscopic cholecystectomy by RI approach. ResultsFrom the total 125 cases, 95 (76%) patients were male and 30 (24%) were female. The mean age was 59.5 ± 5.5 years. The mean operative time in SLC group was 128 ± 17 min VS. 114 ± 10 min in RI group. Conversion to open occurred in 10% in SLC group VS. 1.5% in RI group. Biliary injury occurred in 3.3% in SLC group VS. 0% in RI group. The mean hospital stay in SLC was 3.7 ± 5.3 days VS. 2.1 ± 0.3 days in RI group. ConclusionIn difficult cholecystectomy, RI approach is feasible and safe alternative to SLC.