Laparoscopic Cholecystectomy is no More Risky in Emergent Cases With in Cardiopulmonary Risk: Fundus-Callot Cholecystectomy With Low Pressure Pneumo-peritoneum VS Open Cholecystectomy - Randomized Controlled Trials

1. INTRODUCTION Evolving the role of laparoscopy in the last decades in managing of different surgical diseases especially biliary diseases had made laparoscopic cholecystectomy of special interest in the field of surgery. The wide spread of use of laparoscopic cholecystectomy put this surgery in the front line of the commonest operation performed in digestive system surgery and really put open cholecystectomy a side.[ Gouma DJ, Rauws EA, Lameris JS. Bile duct injury after cholecystectomy: risk of mortality substantially higher. NedTijdscr Genseeskd 2004; 148: 1020-24.]

Laparoscopic cholecystectomy advantages are numerous to both the doctors and the patients. Advantages to the surgeons are safety and rapidity of the operation with experienced surgeons. To the patients as regard small sized operative wounds, less pain postoperative, less wound infection and hence rapid discharge from hospital and regain its usual daily activities . [Stanisic V, Bakic M, Maqgelinic M, Kolasinac H. Babic I. [Laparoscopic cholecystectomy of acute cholecystitis]. Med Preql 2010; 63: 404-8.]

Despite the fact that laparoscopic approach had many benefits over open approach, yet many hazards may occur from laparoscopic cholecystectomy starting with viscous injury during induction of pneumoperitoneum and conversion till fatal biliary and vascular injuries during blind and insisted dissection of disturbed anatomy and frozen Calot triangle. these complications may occur with best surgical hands and decreased with increasing learning curve.[ Russel JC, WalshSJ, Mattie AS, Lynch JT. Bile duct injuries.1989- 1993: A state wide experience: Connecticut laparoscopic cholecystectomy registry. Arch Surg 1996; 131:382-8.][ Atmaram DC, Lakshman K. Predictive factors for conversion of laparoscopic cholecystectomy. Indian J Surg 2011; 73: 42-3] a study put us on the way to avoid bile duct injuries [5].

The incidence of gall bladder disease increase with advancement of age so that 20-30% of patients undergo laparoscopic cholecystectomy is elderly patients > 60 years with cardiopulmonary risks. and increase to 80 % after 90 years .Elderly patients had cardiopulmonary risks and reduced physiological reserve [Festi D, Dormi A, Capodicasa S, Staniscia T, Attili AF, Loria P, et al: Incidence of gallstone disease in Italy: results from a multicenter, population-based Italian study (the MICOL project). World J Gastroenterol 2008; 14:5282-5289.] [Ratner J, Lisbona A, Rosenbloom M, Palayew M, Szabolcsi S, Tupaz T: The prevalence of gallstone disease in very old institutionalized persons. JAMA 1991; 265: 902-903.]. Other study stated lower incidence of acute cholecystitis in the elderly group of only 6%[ S. W. Lee, S. S. Yang, C. S. Chang, and H. J. Yeh, "Impact of the Tokyo guidelines on the management of patients with acute calculous cholecystitis," Journal of Gastroenterology and Hepatology, vol. 24, no. 12, pp. 1857-1861, 2009.]

Insufflation of CO2 induces both hemodynamic and mechanical effects. Compression of the vascular system decrease cardiac output due to increase peripheral resistance. Abdominal distension hinder movement of diaphragm. [ Enciso NJ (2013) Anestesia en la cirugía laparoscópica abdominal. An Fac med 74(1): 63-70.].