Purpose: Biliary injury during laparoscopic cholecystectomy is still a serious problem. Injury occurs as s result of technical errors or misidentification of ducts. This study is aimed to access the clinical effectiveness of modified techniques in difficult cystic duct. Methods: We used two modified techniques in difficult cystic duct. One was Fundus-first laparoscopic cholecystectomy with endoloop ligation (FFLC group). Another one was laparoscopic cholecystectomy via endo-ligation with clipping (Endo-ligation group). We experienced the total 77 cases of the difficult cystic duct among total 450 cases of laparoscopic cholecystectomy underwent by only one surgeon from February 2001 to December 2003. Results: Out of 77 patients to have difficult cystic ducts, 62 patients underwent laparoscopic cholecystectomy via endo-ligation with clipping and 15 patients underwent Fundus- first laparoscopic cholecystectomy (FFLC) with endoloop liga-tion. There was no common bile duct injury in both groups. In the Fundus-first laparoscopic cholecystectomy (FFLC) group, conversion to open cholecystectomy during operation was required in 1 case, and there was 1 case of postoperative bile leakage. In the endo-ligation group, there were 2 cases of postoperative bile leakage. All cases of complication were successfully resolved by conservative management. Conclusion: Fundus-first laparoscopic cholecystectomy (FFLC) and endo-ligation with clipping are feasible and safe for the cases with severe inflammation and fibrous adhesion of gallbladder and cystic duct. Its use reduced the conversion rate (0.2%) and complications including postoperative bile leakage.

Keywords: Cholecystectomy, Laparoscopic, Difficult case, Technique