الفهرس 
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Abstract
Summary and conclusion
Laparoscopic cholecystectomy (LC) has become the gold standard in the treatment of symptomatic gall stones.It has replaced open cholecystectomy as the therapeutic modality in the treatment of cholelithiasis.
The aim of this work is to identify predicting factors of difficult laparoscopic cholecystectomy using clinical and ultrasonographic parameters.
This study was conducted on seventy five patients suffering from chronic calculous cholecystitis and planned for LC.
All patients were compared according to demographic data, clinical data, laboratory profile, abdominal ultrasound result, and operation data.
BMI was found statistically highly significant factor affecting difficulty of peritoneal access when using open Hasson’s technique.
Difficult GB bed dissection was found significantly related to patients with history of acute attacks, Positive Murphy’s sign, history of ERCP, GB wall thickness >3mm and dense adhesion encountered during 1st five min. inspection.
Distended GB and dense adhesions were found statistically significant in increasing the risk of bile and stone spillage during operation.
History of biliary pancreatitis and history of ERCP were found statistically significant as risk factors for bleeding during surgery.
Difficulty of extraction of GB was found in patients with history of ERCP, distended GB, GB wall thickness >3mm and dense adhesions during first five min.
Risk of conversion to open was found significantly related to patients with history of biliary pancreatitis, patient with history of ERCP and dens adhesions encountered during 1st five minutes inspection.
Operative time was found prolonged in cases with history of biliary pancreatitis, history of ERCP, distended GB, Multiple stones and dense adhesions encountered during 1st five min inspection.
This study concluded that concerning predicting factors of difficult laparoscopic cholecystectomy, BMI, history of acute attacks, Positive Murphy’s sign, history of ERCP, history of biliary pancreatitis, GB wall thickness >3mm ,multiple GB stones and dense adhesion dose pose difficulty in various steps during LC.
Recommendations:
• In cases with BMI >32, it is better to uses Verres needle in left hypochondrium to create pnumoperitonium.
• Patients with history of ERCP must be notified about the risk for conversion to open.
• At any time during surgery, if the anatomy is unclear, it is safer to convert to open.
• In cases with history af acute attacks, care should be taken to avoid bleeding during dissection.