The definition of difficult laparoscopic cholecystectomy (LC) is inconsistent. The aim of this study was to analyze the factors that make LC difficult to perform and determine ways to avoid conversion, based on our series. All patients who underwent LC or open cholecystectomy (OC) between January 1993 and December 2001 in our division of general surgery were the subject matter of this study. Preliminary decisions regarding LC or OC were avoided. Our experience (1993-2001) was based on 1360 consecutive elective LC procedures in 381 male and 979 female patients. The mean age of the patients at operation was 53 years (range, 17-84). The median operating time was 55 minutes (range, 35-180). The overall conversion rate was 1.8%. Indications for conversion included surgical difficulty during the laparoscopic procedure and anesthesia issues. The conversion rate has decreased to less than 1% in recent years. There were no mortalities, and the postoperative complication rates were low. The mean hospital stay of the patients was 2.6 days. In conclusion, based on our experience, we suggest limiting OC to patients with proven contraindications to LC (i.e., Mirizzi syndrome or systemic illness incompatible with pneumoperitoneum), attempting LC in all other cases, and considering cholecystostomy and delayed LC as an alternative to conversion during difficult LC.

Our results suggest that MT1XT20 represents a sensitive and specific marker for MSI testing and could be included in a complete set of MSI markers for the confident identification of familial or sporadic dMMR patients in CRCs.

Our study first identified a treatment disparity among different geographic Italian regions. A more systematic audit is needed to confirm these results and plan adequate interventions.

In our hands, LA has proven to be safe and effective. The laparoscopic operation has significant advantages in terms of lower invasiveness and better diagnostic capability. It is especially useful in women of child-bearing age, in whom it may be considered the procedure of choice.

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The technique has a re-educational function, in that patients are induced to chew thoroughly, to introduce small morsels of food and to prolong the mastication time, in order to avoid dysphagia. Laparoscopic adjustable esophagogastric banding gave no problem if well positioned, and promoted new alimentary habits through a dysphagic mechanisms, inducing significant excess weight loss.