الفهرس 
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Abstract
The present study was carried out on 20 patients suffering from chronic calcular cholecystitis and had had previous major abdominal surgery admitted to Menoufiya University Hospitals(general surgery department) excluding patient with acute cholecystitis, current panceatitis ,morbid obesity and common bile duct stone . The aim of this study was evaluation of the effect of previous abdomenal surgery on the feasibility and safty of laparoscopic cholecystectomy . We resorted to the conventional four port technique (two 10 mm and two 5 mm ports) using the North American arrangement. With the patient lying supine, the surgeon was positioned on the patient’s left side and the camera operator on the patient’s left to the left of the surgeon. The video monitor was positioned on the patient’s right. The patients were placed in the head up left tilt position. pneumoperitoneum creation which was done either with cloed method (veress needle ) or open method (Hasson technique). Veress needle is a spring loaded central slim trocar which traverses the rectus sheath and enters the peritoneum. The inner trocar retracts as the needle encounters resistance and springs back on enterng the peritoneal cavity. This spring loaded mechanism had been confirmed to be working prior to initial insertion and also the patency of lumen by checking the gas flow through the needle. We were use the non diposable veress needle which made of metal. There were a sensation of initial resistance, As the needle enters the peritoneal cavity, a distinct click can often be heard as the blunt-tip portion of the Veress needle springs forward into the peritoneal cavity. Open laparoscopic approach(OLA), (Hasson technique) An incision about 1 cm is made below the umbilicus and carried carefully through the line alba fascia. By blunt dissection with a clamp, the presence or absence of underlying adhesions or loop of intestine is determined and if present, pushed aside to allow entery into the peritoneal cavity to remove the adhesions. The 10 mm trocar then passed into the cavity and heled in place by non-absorbable monofilament proline suture to prevent escape of the pneumoperitonium. Clipping of duct and artery (after skeletonizaion of the cystic pedicle) was done using 3 simple titanium clips (2proximal and 1distal) for each, then the gall bladder freed from the liver bed. The gall bladder extracted from the epigastric port and a tube drain was inserted in Morrison’s pouch through the lateral 5 mm port after washout. A final look at the liver bed for any bleeding or bile leak was mandatory. The patients were 13 females and 7 males and the age of the patients ranged from 12-58 years with a mean of 44.00±10.4 It was found that there were 14 cases with previous upper abdominal surgery, 3 of them had underwent gastrectomy (15.0%) (2 open sleeve (10.0%)and one lap sleeve ( 5.0%)),5 cases (25.0%) had undergowen hernioplasty(3 of them umblical, one paraumblical and one incisional). 4 cases(20.0%) had exploration, one case(5.0%)had had pancreatitis, intestinal obstruction and one case(5.0%)had Simple suture with Graham patch (Perforated peptic ulcer) ,rather than 2 cases were undergone exploration for trauma one of them had underwent rt lobe hepatectomy ,and the other were had repair of liver injury. and one case had underwent splenectomy. and 6 cases with lower abdominal surgery,2 of them (10.0%), had Transabdominal gynecologic operations (Hysterectomy, C/S), one case (5.0%)had exploration for appendectomy with peritonitis, one case (5.0%) had nephrectomy, one case (5.0%) had Rt hemicolectomy and the last one had pelvic hemicolectomy. There were 11cases (55.0%) had midline incision ,2 cases (10.0%) had Rt paramedian incsion, one case (5.0%) had Mercedes incision ,4 cases (20.%) had transverse supraumblical incision , one case (5.0%) had lumbar incision and one case had incisions for lap sleeve gastrectomy. Adhesion was present at port site in 2 cases (10.0%) ,at the field in 3 cases (15.0%), at port and field in 6 cases(30.0%),away from the field in7 cases (35.0%),and fine adhesion was present in 2 cases (10.0%). Adhesion score ranged from1–3, median 2 and Mean±SD 2.05±0.76 Adhesiolysis were neded in 11cases(55. 0%)and not needed in 9 cases Postoperative complications as one case(05.0%) shown 2 days postoperative ileus. And 2cases were show minor bleeding from adhesiolysis which were controlled intraoperative with diathermy, gauze piece and suction irrigation. Patients who had previous major upper and lower abdominal surgeries were similar with respect to age, sex, adhesion score, adhesiolysis and postoperative hospital stay p-value>0.05. The mean operative time and complication rate in patient with previous upper abd surgery was longer than that in patient with lower abd surgery and show statistically significant difference P-value<0.05 Based on our study, LC can be performed safely in patients with previous upper or lower abdominal surgery in presence of institutional and surgeon experience, if they do not have such conditions as acute cholecystitis, pancreatitis, CBD stones, and morbid obesity.