Print ISSN: 0027-1446

Online ISSN: 2309-6217

Volume 43, Issue 1

Volume 43, Issue 1, Winter and Spring 2021, Page 1-99

Clinico-Hematological Profile in Patients with Chronic Myeloid Leukemia

Inam Al-abady; Professor Muna Abdulbasit Kashmoola; Professor Khalid N. M. Al-khero

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 1-9
DOI: 10.33899/mmed.2020.128677.1054

Background: Chronic myeloid leukemia (CML) is a clonal malignant neoplasms of pluripotent hematopoietic stem cell described by the excessive proliferation of mature granulocytes and their precursors in the bone marrow and peripheral blood. It is characterized by the presence of Philadelphia chromosome, a translocation between chromosome 9 and 22 or BCR-ABL1 gene.
Objectives: To evaluate clinical and hematological parameters in patients with chronic myeloid leukemia and to assess the risk stratification of these patients according to Sokal and European Treatment Outcome Study (EUTOS) scoring systems.
Setting: This case series study conducted at Ibn-Sina Teaching Hospital/Outpatients Hematology Department from November 2019 to April 2020.
Patients and methods: Total seventy patients with chronic myeloid leukemia included in this study. They involved 64 old cases and 6 new cases. The records of old cases were reviewed for clinical history, clinical examination, previous blood counts, bone marrow study and genetic study, where ever it was available. For new cases clinical history and physical examinations were noted. Complete blood pictures, biochemical tests and molecular study (BCR-ABL) were done at private laboratory. The BCR-ABL done by real-time reverse transcription polymerase chain reaction using Xpert BCR-ABL Ultra test on Cepheid GeneXpert® Dx System. All patients were categorized into different risk groups by using Sokal and European Treatment Outcome Study scores that calculated according to standard formulae.
Results: The males were (57.1%) of patients and females were (42.9%) with male to female ratio was 1.33:1, their age ranged from 16-82 years with a mean of 41.9 years. The most common complains were fatigue (87.1%), fullness in the abdomen (78.6%) and constitutional symptoms (64.3-74.3%). About 96% of patients had splenomegaly at presentation. The mean total leucocyte count was 153.7 x10^9/L, basophilia found in (72.9%) of patients and anemia in (85.7%) of them. By Sokal score, (25.7%) of patients were categorized as low risk, (52.8%) as intermediate risk and (21.4%) as high risk. According to EUTOS score, (60%) of patients were categorized as low risk, while (40%) of them as high risk. There were significant differences in high and low risk groups between two scoring systems (P-values 0.016, 0.000).
Conclusion: Middle age groups (35-54 years) were commonly affected by chronic myeloid leukemia and males were predominance over females. Fatigue, fullness in the abdomen were the most common complains, while splenomegaly was the most common clinical sign. Majority of the patients, when categorized by the Sokal score, fall under the low- and intermediate-risk groups, the same is true for the EUTOS score, which, however, does not have an intermediate risk category.

Efficacy of Urine Cytology in the Detection of Bladder Urothelial Carcinoma: A Retrospective Study in Medical City-Baghdad

Arwa Albarhawi; Professor Muhsin Sahib

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 10-15
DOI: 10.33899/mmed.2021.129565.1078


To make a cyto-histological correlation and to evaluate the diagnostic efficacy of urine cytology in routine

Materials & methods:
From January 2015 to June 2020, one hundred and thirty-nine cases have been included in this case series retrospective study. Subjects were collected from the Ghazi al-Hariri Surgical Specialties Hospital, Medical City, Baghdad, Iraq. Ranging in age from fourteen to eighty-six years, presented most frequently with hematuria, or diagnosed radiologically with bladder tumor, who underwent cytological examination with the histological examination at the same time or within one year.

Patients were mostly between sixty-one and seventy years old (36.7%). The studied group was made of male (61.2%) and female (38.8 %).
Fifty-five patients who were diagnosed as negative/ benign in cytology examination, and histological examination at the same time, eight patients were diagnosed as high-grade urothelial carcinoma when they were diagnosed negative/ benign in the cytological examination, four patients were diagnosed negative in the histological examination when they were reported as high-grade urothelial carcinoma in the cytological exam, thirty-four patients were reported as high-grade urothelial carcinoma, cytologically and histologically. The sensitivity of high-grade urothelial carcinoma detection in suspicious or malignant cases in urine cytology was (80.95%), while the specificity (92.98%). the positive predictive value was (89.47%) when the negative predictive value was (86.88%).

It has always been known that urine cytology is a powerful and effective method for the screening of urothelial carcinoma; specifically, for high-grade urothelial carcinoma, and in the follow-up of patients after surgery or cystoscopy.

Intertrochanteric Femoral Neck Fractures Treated by External Fixation

Professor Mahmood A Aljumaily; yakdhan al saleem; Saher H ALbanna

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 16-20
DOI: 10.33899/mmed.2021.129464.1075

Background: Intertrochanteric femoral fracture (ITFF) is common injury in old age group, there are many options of treatment. External fixation used in the high risk patients.
Objective: To present a case series of ITFFs treated by external fixators.
Patients and method: Twenty six patients with ITFF were treated by external fixation in Alzahrawy private hospital in Mosul, during the period from July 2017 through October 2019.
Results: The mean time of follow-up was 11 months. Twenty two patients showed full union of the fracture by the end of the 4th month and the external fixators were removed. Two patients died due to unrelated medical diseases, and one patient developed pathological fracture in the shaft of femur. The patients had good range of motion in both hip and knee joints. Pin tract infection was the commonest complication.
Conclusion: External fixation is simple, mini-invasive, cost-effective alternative method in the treatment of intertrochanteric femoral fractures.
Key word: Intertrochanteric, Femoral Neck, Fracture, External, Fixation.

The Role Of Selnium On Some Hormones And Histological Structures In Ovaries Of Hypothyroid Female Albino Rats

Eman Ghanim Alhealy; mayson alkazzaz; Professor Wahda Mohammad Taib AL-Nuaimy

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 21-28
DOI: 10.33899/mmed.2021.129035.1063

Background: The appropriate function of the ovary depends on the proper function of other endocrine glands especially the thyroid gland, which is the largest endocrine glands in the body. Hypothyroidism is a common thyroid disorder which commonly affect females and influence the function of reproductive system.
Aim of this study : This work is to focus on the structural changes in ovary of adult female rats induced by hypothyroidism and the role of selenium.
Methods: Thirty adult female rats were used. They were classify into 3 groups (10 animals in each group): Group I ( control) taken 0.5 ml distilled water orally for 3 months . Group II ( hypothyroid ) they were given antithyroid drug, carbimazole in a dose of 6 mg/ kg orally by gastric tube for 3 months. Group III (hypothyroid + selenium ) this group were treated by carbimazole as same as group II then added selenium in the last 2month in a dose of 10 µg/ kg orally. At the end of experiment , blood samples were taken for assessment of serum TSH ,T4 , FSH, LH, and estradiol, then animals were sacrificed and the ovaries were fixed in 10% formalin solution and prepared to be examined under the light microscope.
Results: Serum concentration of TSH was significantly increase while the level of T4, LH, FSH, and estradiol concentrations were significantly decreased in both treated groups. The ovaries of hypothyroid groups showed degenerative changes of most growing follicles. Many atretic follicles and corpus luteum were observed with increase of collagen fibers and edema in the stroma associted with congestion of blood vessels. Treating of hypothyroid rats with selenium for two months produced an improvement in hormonal level and histological structure of the ovarian tissue.
Conclusion: Hypothyroidism affect the structure of ovarian tissues but adding selenium has ameliorative role on thyroid function and histological changes of ovary which may be attributed to its antioxidant activity.

The Value of Using Grey Scale Ultrasound in the Estimation of Palpable Breast Lumps in a Specialist Breast Clinic in Mosul City of Iraq

Marwa Ismail khalaf; Israa Basheer Abd Allah

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 29-34
DOI: 10.33899/mmed.2021.129441.1073

Abstract: Breast carcinoma is one of the most common female malignancies affecting the females within the 30-60 years age groups in many parts of the world. The aim of the study was to assess the using of grey scale ultrasound in the evaluation of palpable breast lumps in Mosul city and compare the finding with the histopathology.
Materials and Methods: The study was retrospective study which was done at Al-Khansa Specialist Breast Clinic, from January 2019 to July 2019. 155 patients with palpable breast lump were evaluated by grey scale ultrasound and their characteristics radiological features were studied and compared with the final histopathological diagnosis.
Results: By ultrasound, about 60% of the cases were benign, 13.5 % were intermediate and 26.4 % were malignant compared with the histopathology which showed 71.6 % were benign and 28.4 % were malignant. The most common benign lesion was fibroadenoma while mastitis was the most common intermediate lesion diagnosed on histopathology. The specificity and sensitivity of the ultrasound in detection of breast carcinoma were 92.7% and 88.6% respectively. PPV of 82.9% and NPV of 95.3% with diagnostic accuracy 91.6%.
Conclusion: In our study, the grey scale ultrasonography has high specificity, sensitivity and diagnostic accuracy in detection of breast carcinoma to reduce the morbidity and mortality of the disease. In general, ultrasound' s availability and low cost in developing countries and comfort to the patients with no radiation effect; making it considered as 1st line investigation modality in females breast lumps.

Spontaneous Rupture of Hydatid Cyst of the Liver in Pediatric Age Group Four Rare Cases with Literature Review

Professor Abdulrahman sulaiman

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 35-41
DOI: 10.33899/mmed.2021.129224.1068

Hydatid cyst of the liver is usually asymptomatic, it may be diagnosed accidentally or when there is complications. It is more seen in endemic areas like Iraq and frequently seen in children. The author reports four rare cases of spontaneous rupture liver hydatid. They were admitted and treated at pediatric surgery center at Alkhansaa teaching hospital in Mosul. One of them ruptured to pleura, the second case had rupture to peritoneum with intact endocyst, while the third rupture to extra peritoneal space. The forth patient has direct rupture to peritoneal cavity with hundreds of daughter cysts. Liver hydatid cyst rupture is a serious complication. It comes in the differential diagnosis of acute abdomen in endemic areas. It needs urgent management. Anti helminthic therapy is needed post operatively in all of them
Case summaries
Four Iraqi children aged between 5.5-10 years (three boys and one girl) were referred to pediatric surgery center with differing presentation. Abdominal pain is the main presenting feature. One of them with predominant respiratory infection symptoms while the forth one with allergic reaction (tab1). Ultrasound and Chest X-ray were our main tool for the diagnosis. CT was used in two of them. Laparotomy was done in three of them while thoracotomy was performed in one.

Lumbar Spine MR Imaging : Relation Between Edema Like Signal in the Posterior Soft-Tissue and Body Mass Index

Sameeah Abdulrahman Rashid; Mohamed Muyaser Naif; Hadeel Mohamed Farooq

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 42-47
DOI: 10.33899/mmed.2021.129226.1069

Background: It is not uncommon to encounter edema like signal within the soft tissue of the posterior lumbar region in MRI of the spine; however the exact explanation of such edema is not established yet.
Objectives: To find out relationship between edema like lesion in the soft tissue of the posterior lumbar region on spine MRI with BMI, age and gender
Patients and Methods: Lumbar Spine MRI of 288 outpatients suspected to have disc disease ( 150 females and 138 males ) performed on 1.5 Tesla facility was evaluated. Subjects with systemic or local disease likely to produce edema were excluded to obtain healthier subjects. The scans were reviewed for presence, site, and degree of High T2 edema like signal within the posterior lumbar soft tissue . The subjects were divided into four subgroups according to BMI and two groups according to their age(≤50 or>50 years old). The edema was scored from 0-5 based on its length relative to vertebral-body height. Correlation between the presence and extent of edema was made with BMI, age and gender .
Results :Among the 288 cases, 116 (40%)patients had lumbar soft tissue edema. Association was found between the degree of edema and BMI ( P= .001) and with age ( P= .041) . The presence of edema was noticed to be significantly more among women (P=.045) , while the average level of edema epicenters was approximately similar ( L3.6 and L 4 consequently, P = .58).
Conclusion :There is a positive relationship between the frequency and extent of posterior lumbar soft tissue edema with BMI and age .

Assessment of Clinical Indications for Caesarean Section in Mosul City Hospitals: A Cross-Sectional Study

Noor Nazar Fadhl; Omaima Abdulrazzaq Zubair; Raida Muhammed Al-Wazzan

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 48-54
DOI: 10.33899/mmed.2021.129023.1061

Background: Caesarean section is traditionally done when a vaginal delivery would put the mother or fetus's life at risk. Knowing the indications of the caesarean section will help to have an impression of this common type of the obstetric procedures. The aim of the current study was to examine the indications of caesarean sections which are undertaken in Mosul city hospitals.
Methods: A cross-sectional study was done at eight hospitals in Mosul city and a sample of 671 women who were delivered by caesarean section was included in this study. The necessary agreement was obtained from all the participants in the sample.
Study period: the study was done during the period from 15th November 2019 to 15th April 2020. The information was taken by direct interview with the women who were delivered by caesarean section and from their hospital case sheets.
Results: Primary caesarean section was reported in 45.2% of cases followed by previous two or more CS in 32.3% and those with previous one caesarean section with other causes 22.5% with a very highly statistically significant difference (P=0.001). Fetal distress was the indication for primary caesarean section in one-quarter of cases 25.4% with a very highly statistically significant difference (P=0.000) from other causes. Maternal request constituted 11.5% of indications among the participant women and it constituted one-quarter of causes among women with previous one caesarean section (P=0.000).
Conclusions and recommendations: Primary caesarean section constituted the highest number among caesarean section indications in the current study, followed by previous two or more caesarean section and then previous caesarean section with other causes. Fetal distress was the highest indication in primary caesarean section cases. The study recommends to improve health education to the mother about the risk of caesarean section and possibility of normal delivery after primary caesarean section.

Surgical Outcome and Prognosis of Spinal Missile injuries

Ali Hikmat Azeez; Nashwan Yaseen Sallama; Saad A. Yahya Alsaqa

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 55-59
DOI: 10.33899/mmed.2021.129309.1070

Background: The spinal cord is so sensitive to injury. Once it is damaged; it shall lose its ability to repair itself .Unfortunately spinal cord injuries (SCI)are common in Iraq . It could be either complete or incomplete SCI. In the complete injury there is a total loss of sensation and motor function in the level below the site of the injury, while in the incomplete one there is some remaining neurological functions below the level of the injury.
Objectives: The aim of this study is to compare the surgical and conservative management of complete and incomplete spinal cord Injuries due to missile in Mosul city.

Patients and methods: A case series study of (60) patients with missile cord injury of the spine who were managed in the Neurosurgical Department at Ibn-Sina Teaching Hospital in Mosul from August 2011 – August 2013. The mean patient age was 30 years. Thirty three (55%) patients were surgically treated. The mean time of follow up was 9 months ranged from 6-18 months. All patients had complete radiological assessment, CT scan and one patient with through and through bullet injury magnetic resonance imaging( MRI) was done after initial resuscitation.

Results: All patients with complete spinal cord injury did not improved after non-surgical management, after surgical removal of bullet and it's pressure effect from the spinal cord just one case with conus medullaris injury gets improvement. Those with incomplete injuries show good improvement after surgical management.
Conclusion: Conus medullaris and cervical injuries show a better outcome in surgical treatment than those out surgical intervention in incomplete spinal cord injuries. There were no difference between the outcomes of surgical and non- surgical management of complete neurological injuries of the spinal cord.

Evaluation of the histology and the oxidative stress status in the placentas of obese mothers

Harith Ali; Luma Al-Allaf

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 60-69
DOI: 10.33899/mmed.2020.128004.1044

Background: Obesity become one of the most universal medical problem that affect women at reproductive periods.
Aim: To highlight the placental changes in obese mothers and to determine their relation to the oxidative stress.
Methods: This work is prospective case- control study which were examined placentas that were obtained from 60 singleton pregnant women who delivered at Al-Khanssa Maternity Teaching Hospital, Mosul, Northern of Iraq starting from January 2020 to March 2020. The women were classified into three groups: Group 1. Includes (control) women who has BMI ranged between 18-24.9 kg/m2 (N=20), Group2. (Overweight) includes women who has BMI ranged between25-29.9 kg/m2 (N=20), Group 3. (Obese group) includes women with BMI ≥30 kg/m2 (N=20).Two placental biopsies were obtained from maternal side and fetal side of each case and submitted for histological examination via light examination. In addition, Fresh placental specimens (0.5gm) to be taken from all study groups and to be frozen until the time of procedure for oxidative stress analysis.
Results: The Histological sections of group 2 and 3 placental disc revealed that the placentas of these groups manifested different histological changes in comparison with those of group 1. These changes includes syncytial knotting , villous hypovascularity, villous fibrinoid necrosis, The thickening of trophoblastic basement membrane, Cytotrophoblastic hyperplasia , perivillous fibrin deposition ,increase in number of nucleated red blood cells (NRBC), Stromal fibrosis, Chorangiosis ,paucity of vasculosyncytial membrane VSM, villous edema, features of deciduitis, villitis, and increase the thickening of tunica media of the placental blood vessels. The biochemical analysis of the level of malondialdehyde (MDA) in the placental homogenates of the three study groups revealed a significant increase of its level in homogenates of group 2 and 3 in comparison with that in group 1 homogenates indicating the presence of the oxidative stress.
Conclusion: this work revealed a marked increase in the level of MDA in placental homogenates of the obese and overweight groups in comparison with that of control group suggesting the role of the oxidative stress.

Review of Different Methods of Uncinectomy in Endoscopic Sinus Surgery

Haitham Alnori

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 70-75
DOI: 10.33899/mmed.2021.129601.1079

Uncinectomy is a safe procedure in experienced hands whatever technique is used. It is usually the first step in endoscopic sinus surgery and the first surgical maneuver the new rhinologist has to learn. The most familiar two methods of doing uncinectomy are the classic method, introduced by Stammberger in 1986, and Wormald’s swing-door technique in 1998. The swing-door technique appears to be associated with a slightly higher risk of injury to the lacrimal duct. Simultaneously, failure to identify maxillary ostium and orbital penetration are both more common in the classic method.
This study aims to review the different methods of doing uncinectomy during endoscopic sinus surgery and compare the most standard techniques regarding their efficiency and safety.

Huge Biloma in a child with unusual presentation

Professor Samir Ibrahim Hasan AlSaffar

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 76-80
DOI: 10.33899/mmed.2021.129534.1077

The term "biloma" describes a well-demarcated, encapsulated or not, intra-abdominal (extrahepatic or intrahepatic) bile collection outside the biliary tree, secondary to iatrogenic, traumatic or spontaneous rupture of the biliary tree. The clinical symptoms of bilomas are usually nonspecific, ranging from no symptoms to abdominal pain, jaundice, and fever. There were only few cases of huge bilomas in the literature but no report of conincidental extrahepatic and intrahepatic biloma in the same patient.
Case report:
We report herein a 12 years boy with huge biloma (20cm in vertical diameter) after blunt abdominal trauma, presented with unique clinical features of marked emaciation and diffuse abdominal distention . To our knowledge this is the largest biloma ever reported in paediatric age group and the first biloma with such unique clinical presentation, and the first case with both extrahepatic and intrahepatic bilomas in single setting.
Although biloma is rare condition but it needs to be considered in differential diagnosis of diffuse abdominal distension in patients following abdominal trauma or surgery.

Endoscopic Dacryocystorhinostomy: A Case Series Study from Mosul City

Islam Ghanim Mahmood; Professor Ali Abdulmuttalib Mohammed; Hassan Myasar Abdulwahid

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 81-86
DOI: 10.33899/mmed.2021.129046.1064

Background: Dacryocystorhinosty is a technique applied to patients who complain of excessive tearing (epiphora) and demonstrate obstruction of the lacrimal outflow system.
Objectives: The present study aims at studying the outcome and complications
of endoscopic dacryocystorhinostomy EnDCR.
Methods: This case series study was conducted to analyze 70 eyes related to 66 patients with epiphora and recurrent attacks of dacryocystitis who underwent EnDCR for the period from January 2018 to June 2019. Surgeries were done in 2 hospitals in Mosul namely; Al-jumhoory Teaching hospital and Al-Rabee Private hospital.
Results: This case series study included 70 eyes of 66 patients (62 unilateral and 4 bilateral cases) complaining from epiphora excessive tearing and/or chronic dacryocystitis. There was 45 females (68.2%) and 21 males (31.8%) with F:M ratio of 2.1:1. The patients, ages ranged between 4-74 years of age with a mean age of 39 ± 18.31. The success rate of endoscopic dacryocystorhinostomy EnDCR in the present study was 97.15 % depending on clinical improvement of epiphora , endoscopic assessment for patency of the new ostium and passage of tears aided by pressing over the medial canthus. Hemorrhage was the most common complication and there was no serious orbital complication in our study neither during surgery nor in the follow up period.
Conclusion: Endoscopic dacryocystorhinostomy EnDCR carries very good success rate with relatively not critical and low complication rate. Moreover, it has the advantage of overlooking unnecessary scar, the ability to operate both sides simultaneously and revising the operation in case of failure of surgery.

Superior Mediastinal Teratoma- A Case Report with review of literature

Elaf Abdulwahhab Hamdi; Rabea Salim Abd Aljabbar Sofi Ali; Professor Wahda Mohammad Taib Al-Nuaimy

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 87-90
DOI: 10.33899/mmed.2021.129189.1065

"A teratoma is a germ cell tumor composed of tissue derived from two or three germ layers-ectoderm, mesoderm, and endoderm". Teratomas are mostly found in children & young adults & usually originated in gonads & midline tissues. They have also been reported in extragonadal sites, such as retroperitoneum, sacrococcygeal region & mediastinum. Mediastinal teratomas are relatively rare comprising 8-13% of all tumors in mediastinum and 1- l0% of germ cell tumors developing in mediastinum. We are presenting a case of 39 years old male who presented with progressive exertional dyspnea, orthopnea with frequent attacks of cough for 3years and feeling of pulsatile mass in left upper parasternal area in the last 4 months. Chest x-ray showed superior mediastinal shadow projecting to left upper chest zone and deviating the trachea to the right side of chest, differential diagnosis was aneurysm of aortic arch. Computed tomography (CT) scan of chest and CT angiography done and revealed a superior mediastinal mass of heterogeneous opacity containing fluid, soft tissue, bones and calcification encroaching the right pulmonary artery and compressing and deviating the trachea to the right. Complete surgical removal done through left thoracotomy, Final diagnosis of a mature cystic teratoma was given on histopathology. This case is being presented here because mediastinum is a rare site for teratoma and superior mediastinum was not reported as a site for teratoma from review of literature.

Implementing a modified intraoperative grading system for a difficult laparoscopic cholecystectomy

Yarub Momtaz Tawfeek Al-Hakeem; Professor Nashwan Qahtan Mahgoob

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 91-99
DOI: 10.33899/mmed.2021.128336.1047


Objective: To analyze intraoperative grading findings during elective laparoscopic cholecystectomy by which we can assess the surgical performance regarding its safety, achievability and to determine a safe operative approach and/or time for conversion.

Design: An observational prospective case series study.

Setting: During the period from June 2018 to January 2020, operations were done by 4 qualified consultant surgeons and their teams at 4 hospitals in Mosul and Erbil.

Participants: Two hundred and fifty-five patients.

Patients and Methods: All patients underwent elective laparoscopic cholecystectomy for symptomatic gallbladder disease after full evaluation and taking their informed consents. An intraoperative difficulty calculation score has been implemented that divide the situation into 4 grades: easy, difficult, very difficult and extremely difficult, depending on the appearance of the gall bladder wall color, amount of adhesion, the presence of anatomical abnormalities, and the ability to achieve the critical view of safety. Perforation of the gallbladder, slipped stones, bleeding, using extra instruments, the need for extending the epigastric incision, the use of a drain and conversion to open procedure as well as the duration of surgical intervention had been recorded as predictors for the assessment of the difficulty level during surgery.

Results: The first grade included 168 (66%) patients, the second grade included 62 (24%) patients, while grades 3 and 4 represent 15 (6%) and 10 (4%) of patients respectively. Perforation showed no significance in the grading. Bleeding was more common in grades 3 and 4. Using accessory equipment was mandatory to complete the operation in grade 4 as well as an extension of epigastric port and the need for putting a drain. Conversion to open cholecystectomy was done in 2 operations (0.7%), both belonged to grade 3 and 4. The time needed to accomplish the operation was significantly high in grades 3 and 4.
Conclusion: This modified grading score can provide a tool for reporting operative findings and technical difficulties during laparoscopic cholecystectomy that allow the surgeon to know the seriousness of the situation and taking effective measures to overcome it.