Emergency Laparoscopic Cholecystectomy With Low Pressure Pneumo-peritoneum in Cardiopulmonary Risk Patients: Fundus First Cholecystectomy VS Calot First Cholecystectomy .Randomized Controlled Trials.

1. INTRODUCTION Introduction of laparoscopy in management of cholithiasis gave a great push to dealing with this disease. The advancement of laparoscopic cholecystectomy had greatly evolved in the last years making laparoscopic cholecystectomy is the commonest operation performed within field of gastrointestinal tract surgery and almost replaced open cholecystectomy.[1] [2]

After introduction of laparoscopic cholecystectomy, many advantages the patients gained over open cholecystectomy as small operative wounds with minimal postoperative pain and infection and hence rapid discharge from hospital. Other advantages are better cosmosis, earlier resumption of oral feeding and rapid restoration of daily activity and work. [3]

Although laparoscopic cholecystectomy had many advantages over open approach yet, many disadvantages emerged after the wide spread use of laparoscopic cholecystectomy as higher incidence of bile duct injuries that may reach 0.3-0.8% that may increase in acute emergent cases. This is a grave problem that may cause mortality to the patients. [4]Strasberg gave us the best solution up till now and the way to avoid injury to biliary tract. [5].Other complications the patients may face after laparoscopic cholecystectomy are organ injury; vascular injury and obstructive jaundice from missed stone in common bile duct during the operation. [6]

About 30% of patients undergo laparoscopic cholecystectomy are elderly patients with cardiopulmonary risks [7]

Co2 insufflation into the peritoneal cavity exerts bad effects on cardiac and respiratory systems and may worsen the condition of cardio-pulmonary risk patients. Pneumo-peritoneum with CO2 causes splintage of the diaphragm, hypercarbia with arrhythmias, compression of main abdominal vasculature (Inferior Vena Cava and abdominal aorta) and stretch of the peritoneal cavity with consequent parasympathetic irritation causing baradycardia.[8][9][10][11][12].