The difficult cholecystectomy: problems during dissection and extraction.

All surgeons will encounter difficult cholecystectomies. Many trying and untenable situations can be prevented or made easier by the cautious surgeon who has a carefully thought-out plan for each potential problem. Step-by-step, this article addresses the arduous challenges that may be faced beginning with diagnosis and continuing through the operative procedure including the decision to operate, the best intervention, abdominal entry, dealing with common duct stones, intraoperative cholangiography, exposure of the biliary anatomy, avoidance of bleeding or common duct injury, spilled stones, and postoperative bile collection. Each problem is addressed with emphasis on prevention and management.