A study indicated that 25–38% of the patients who complained of acute cholecystitis are elderly male diabetic patients underwent laparoscopic cholecystectomy . in the present study, about 134 cases (30%) of cases were elderly diabetic above 60 years mostly female and mostly complained of ASA II. About 67% of cases (315 cases) were above 40 years.
A study stated that previous upper abdominal surgery may increase the risk of viscous injury during trocar induction due to adhesion at the site of previous scar .In the present study; about 13% of cases in Group A underwent previous abdominal surgery and 6% in Group B. No viscus injury as all cases underwent Hasson technique for intra-abdominal access under direct vision.
Bradycardia may develop with induction of pneumoperitoneum due to distension of the peritoneum with parasympathetic irritation. If occurred, immediately deflate the abdomen . In the present study, we started with 8 mmhg intraperitoneal pressure and gradually increased to 10 mmhg not more. Only 5 cases showed hypoxia and bradycardia.
Neri et al stated that the duration of laparoscopic cholecystectomy was shorter in fundus first approach than classical Calot first dissection (70 min and 90 min respectively) and difficult cases of Calot first dissection were converted into open approach without any attempts for fundus first approach. . This is similar to our results that concluded that fundus first initial approach has shorter operative time that classic initial Calot dissection and most cases of fundus first approach took up to 90 minutes in Group A while in Group B, most cases took more than 90 minutes (55%). This is attributed to the low pressure of intraperitoneum making the retracted fundus hits the anterior abdominal wall making exposure of Calot triangle very difficult but it is not in cases of initial fundus first approach.
Bleeding during operation may be either minor bleeding from cystic artery stump slippage and omental vessels bleeding or major bleeding from torn liver and big vascular injuries. Portal vein or hepatic artery bleeding may account for 0.03–10% of cases and is responsible for the second cause of death after complications related to anesthesia. .In this study, intraoperative bleeding occurred in Group A in 2% of cases from cystic artery bleeding (1%) and omental blood vessel bleeding in (1%).both cases were controlled laparoscopically. in Group B, most bleeding occurred from liver tear during extensive fundus traction in the hope to expose Calot triangle (7%) that was controlled laparoscopically by electrocoagulation, cystic artery stump bleeding (7%) and omental vessels bleeding (3%) that controlled laparoscopically by ligation. Seven cases of bleeding cystic artery were controlled laparoscopically and eleven cases of cystic artery slippage bleeding cannot be controlled laparoscopy and required open exploration to control bleeding. No cases of major blood vessels injury occurred in both groups.
A study stated that fundus first cholecystectomy decrease the rate of complications  while other study stated the opposite. .In the present study, fundus first approach much decreased the complication rate. Dissection of the fundus first allow traction of the fundus easy in the condition of low intraperitoneal pressure that help expose of Calot triade then we start dissection in the Calot triade to get critical view of safety and adequate envision cystic duct, Common duct of bile, hence decrease the incidence of biliary injury. Intraoperative bile duct injury occurred in 1% of cases in Group A and it was minor common bile duct injury that repaired laparoscopy while the incidence was 5% of cases with Calot first dissection. Seven cases were minor common bile duct injury that repaired laparoscopically, two cases were transected common bile duct that necessitated open exploration and hepatico-jejunostomy, two cases were injury to right hepatic duct that necessitated exploration and repaired over T-tube drainage. Intraoperative bile duct injury is detected by staining the operative field with bile. Intraoperative colonic and duodenal injuries occurred in group B only and they were discovered intraoperative. Four cases of colonic injuries occurred and 2 of them were minor perforation that were controlled laparoscopy while the other 2 cases required exploration and repair in one case and simple loop colostomy in the other case that was closed after 2 month. Duodenal injuries occurred in 6 cases, 4 cases were minute perforation that is repaired laparoscopically by repair over omental patch, while 2 cases required exploration and repair the big tear with suture over omental patch and gastrojejunostomy.
Many studies stated that conversion rate with fundus first approach may be as low as 1.2% .while other studies reported higher conversion rate 50%,20%,18.5% ,23% and 50% respectively.[22–26]. In the present study, Lower incidence in fundus first group (4%) while the higher incidence were in Calot first approach (14%).
Postoperative bleeding occurred in 3% of Group A and 11% of Group B cases. Postoperatively these patients developed hypotension, tachycardia and continuous fresh bleeding from the drain. Initially these patients underwent conservative treatment in the form of fresh blood transfusion and intravenous fluid. two cases in group A continued to bleed and required re-exploration and revealed cystic artery clip slippage that was controlled by ligation and the other cases was due to post site bleeding that was controlled by trans fixation suture.in Group B, eight cases continue to bleed. Five cases due to slippage of cystic artery clip that were controlled by careful identification of the stump and ligation by suture. two cases were due to port site bleeding that were controlled by trans fixation sutures(figure of 8).the last case was due to greater omental portal arteries that is big enough that required ligation.
In several literatures, up to 1.3–1.5% can occur in bile duct injuries with biliary leakage after laparoscopic cholestectomy. [27–28].Other literature described incidence up to 3%. . in the present study, postoperative biliary leakage is noted in 2% of Group A and 6% in group B. the condition is diagnosed postoperative by abdominal pain, fever, sonar evidence of gall bladder bed collection that revealed bile by aspiration and bile drainage from intra-abdominal drain. Most cases were found in 2–3 days after surgery. Cases of drying less than 200 mL (n = 10) of the bile have undergone conservative treatment in the form of nothing in the oral, cephalosporin and spasmolytic in the third generation, with sonary catheter drainage of the collections. Three cases draining more than 500 ml of bile per day underwent urgent endoscopic retrograde cholangiopancreatography with plastic stenting. Most cases were slipped cystic duct stump clips and others were minor common bile duct injury. These cases improved immediately with no bile drainage from the drain. Three cases showed complete cut of right hepatic duct in two cases and transection common bile duct in one case with dye extravasation on ERCP and treated with re-exploration and hepaticojejunostomy.
A study stated that surgical site infection is common in emergent cholecystectomy. . In this study, 2% of cases in Group A and 5% in Group B .
Postoperative biliary strictures developed in 2% of cases of group A and 14% in group B. mostly discovered after 10th months postoperatively. Patients present with abdominal pain, slight jaundice and elevated liver enzyme. All cases underwent ERCP with balloon dilatation and stenting.
In the present study, the incidence of mortality was 2% in group A and 9%in group B.2 cases underwent laparoscopic approach died of bradycardia and cardiac arrest (one case), the other died of biliary injury sequelae. These cases died in 2nd day and 7th day postoperatively. 21 cases underwent open cholecystectomy showed mortality. bradycardia with heart arrest(2 cases),biliary fistula sequelae (4 cases),colonic injury(one case),duodenal injury(two cases),hypertensive stroke(2 cases) and atelectasis(10 cases).