Introduction
Cholecystectomy is a common procedure in the United States for gallbladder removal due to gallstones, inflammation, large polyps, and pancreas inflammation.1 The laparoscopic technique was introduced in 1985 and replaced open cholecystectomy in the early 1990s.2, 3 Open cholecystectomy was limited to gallbladder cancer cases, while laparoscopic cholecystectomy had advantages such as less post-operative pain, early bowel function return, improved cosmesis, short hospital stay, early return to full activity, and low cost.4, 5 Laparoscopic cholecystectomy has displaced open cholecystectomy in managing simple biliary lithiasis and is a safe, efficient technique for acute (cholecystitis) cases. However, due to intraoperative complications, with a rate of 2-23%.6, 7 Laparoscopic cholecystectomy may become one of the most complicated surgical operations due to anatomical variations, dense adhesions, and contracted or gangrenous gall bladder.6, 7, 8 Preoperative assessment is essential to identify risks and complications, and the surgical team should be ready to improvise the plan to prevent complications and improve post-operative outcomes.8, 9, 10
Surgery is an art that involves refinement and enhancement through personal experiences, resulting in better results for complex procedures, especially in patients with challenging anatomy. Surgical skills depend on the surgeon's knowledge of relevant anatomy.11, 12 Factors such as age, male sex, obesity, comorbidities, ASA score, anatomical variations, previous surgeries, and pathologies can influence the difficulty of laparoscopic cholecystectomy. Intra-operative findings like gall bladder appearance, distension, access to the peritoneal cavity, local complications, and time taken in dissection of Calot's triangle indicate difficulty.13, 14, 15 Surgeons must have knowledge of relevant anatomy and anatomical variations for safe procedures.16 This study identifies clinico-radiological factors predicting difficult laparoscopic cholecystectomy, improving preoperative planning and patient outcomes. It reduces conversion rates to open cholecystectomy, enhancing surgical preparedness and patient counseling, ultimately improving healthcare delivery.
Aims of this study that to assess clinical and radiological factors that predict difficult laparoscopic cholecystectomy.
Materials and Methods
This was a Prospective Observational study conducted at Department of General Surgery, Integral Institute of Medical Sciences and Research in Lucknow over a period of September, 2022 to May, 2024. Total 90 Patients selected for Elective Laparoscopic Cholecystectomy and those with ultrasonographically proven cholelithiasis were included, while those with significant co-morbid illnesses or unfit for pneumoperitoneum creation were excluded.
All Patients were informed about surgery procedures, demographic details, and prior medical history. They were evaluated for hematological, biochemical, immune, and urinary issues. Chest X-rays were obtained, and a USG whole abdomen assessment was performed. Results included demographics, clinical evaluations, laboratory findings, and USG findings. The patient's pain episodes, palpable gallbladder, abdominal scar, palpable liver, and pain duration were noted. Laboratory findings included CBC, SGOT, SGPT, ALP, and lipid profile. The study used criteria to predict difficulty in laparoscopic cholecystectomy, with a total score of 5 - easy, 6-10 difficult, and >10 very difficult. Patients underwent the procedure, with pre-anesthesia screening and intraoperative variables such as time, stone spillage, and conversion to open cholecystectomy.
Table 1
Level of ease of surgery
Statistical analysis
Data analysis was performed using IBM SPSS Stats 25.0 software. Continuous data was represented as mean±standard deviation, while categorical/qualitative data was represented as numbers and percentages. Chi-square tests, ANOVA, and t-tests were used to compare data. The predictive value of the scoring system was assessed, including sensitivity, specificity, positive and negative predictive values.
Results
Total 90 patients aged 15-70 years, with a majority aged ≤50 years. The majority were female (77.8%), with 22.2% males. The mean BMI of the patients ranged from 18.5 to 30.0 kg/m2, with 48 patients having a BMI <25 kg/m2, 34.4% in the 25-27.1 kg/m2 range, and 12.2% with a BMI >27.1 kg/m2.
The most common finding in patients with abdominal scars was wall thickness >4 mm, followed by previous hospitalization, impacted stone, and other factors. The surgery duration ranged from 25 to 95 minutes, with most patients undergoing less than 45 minutes. Intraoperative adhesions were present in 27.8% of cases, and extraction was difficult in 23.3%. Patients were classified as easy, difficult, or very difficult based on their level of ease of surgery.(Table 1)
Table 2
Study population analyzed for intra-operative findings, clinical profile, and investigation findings according to level of ease of surgery
Total 90 patients undergoing laparoscopic cholecystectomy, it was found that 5.6% of patients were very difficult, while 17.8% were difficult. The majority of procedures were classified as easy (76.7%). The study found that patients who underwent easy surgery were younger (36.91±10.63 years) and had a higher ease of surgery (91.2%) compared to those who underwent difficult/very difficult surgery (68.2%). The proportion of difficult/very difficult surgery was higher in males (30.0% vs. 21.4%), but this difference was not statistically significant.(Table 2)
Table 3
Association of demographic variables, body mass index and level of ease of surgery
The study found a significant trend in difficulty with increasing BMI, with a higher proportion of difficult/very difficult cases in cases without hospitalization history. The proportion of those without comorbidities was higher in easy procedures (94.2%) compared to difficult procedures (28.6%). The presence of a supraumbilical scar also showed a significant association with difficulty (p<0.001).(Table 3)
Table 4
Association of USG findings and level of ease of surgery
Gall bladder palpability significantly correlated with surgery difficulty(p<0.001). Pre-operative USG examination findings also influenced surgery ease. The proportion of difficult/very difficult surgery cases was higher among those with GB wall thickness >4 mm and those with impacted stones. The majority of cases with Mucocele/Pyocele detected on USG had difficult/very difficult surgery (90.0%), while the majority of cases without purulent collection had easy surgery (85.0%). This difference was statistically significant.(Table 4)
Table 5
Association of USG findings and level of ease of surgery
A pre-operative scoring system for difficult laparoscopic cholecystectomy was developed using demographic, clinical, laboratory, and USG findings. The system ranged from 0-5 to 11-15 difficult surgeries, with a mean predictive score of 0-7 for easy surgery and 2-12 for difficult/very difficult surgery. The majority of surgeries were predicted as easy, followed by difficult (18.9%) and very difficult (5.6%). (Table 5)
Table 6
Distribution of study population according to predictive score results (N=90)
|
SN |
Predictive score |
No. |
% |
|
1 |
0-5 (Prediction Easy) |
68 |
75.6 |
|
2 |
6-10 (Prediction difficult) |
17 |
18.9 |
|
3 |
11-15 (Very difficult) |
5 |
5.6 |
|
|
Mean Predictive score ±SD (Range) |
3.36±3.12 (0-12) |
|
The study found that 66 out of 68 patients predicted as easy underwent surgery easily, with 66 (97.1%) being difficult to operate. The majority of the 17 patients predicted as difficult were difficult during surgery, with all five patients predicted as very difficult being very difficult intraoperatively. Demographic and clinical variables such as age, BMI, hospitalization history, comorbidities, and presence of supraumbilical abdominal scars were associated with ease of surgery. USG findings also showed significant associations with ease of surgery. The predictive score based on clinical, laboratory, and radiological findings showed significant associations with ease of surgery. (Table 6)
Discussion
Laparoscopic cholecystectomy has replaced open surgery for treating symptomatic gall bladder stones, with gallstone disease impacting surgeons' daily routines. However, few patients require conversion to open cholecystectomy, and patients may face difficulties during the procedure or conversion. Patient experience and satisfaction are not limited to procedure ease or length of stay but also include post-operative symptom re-emergence, impacting their quality of life. Predicting difficulties during laparoscopic procedures can help develop better management strategies. Studies have identified modifiable predictors of difficulties, which have reduced the rate of difficult procedures. However, the rate of difficulties depends on skill level, surgeon experience, and the evolution of new techniques and instruments. Understanding intraoperative difficulties can also help determine post-operative experience and patient satisfaction.
The study aimed to identify preoperative predictors for difficult laparoscopic cholecystectomy in 90 patients, with a mean age of 40.24 years and 77.8% females. The study assessed difficulty using objective criteria based on intraoperative variables like time taken for surgery, bile stone spillage, and conversion to open procedure. The mean BMI of patients was 24.60 kg/m2, with 42 (46.7%) being overweight or obese. Compared to previous studies, the mean age was slightly lower but the proportion of females was slightly higher.17 The majority of patients were ≤50 years old, Majority of patients were ≤50 years of age (73.33%), females (80%), and majority (73.3%) had BMI <25 kg/m2. Some studies reported a dominance of females over males, but the mean age of patients was higher than 50 years.18, 19, 20, 21, 22, 23 Gall bladder disease and cholelithiasis are common problems affecting middle-aged adults, especially women in India.24 Lifestyle disorders like overweight and obesity are increasingly recognized as potential risk factors for gall bladder diseases requiring surgical intervention.24, 25
The study found that 21/90 procedures were categorized as difficult intraoperatively, but no conversion to open procedure occurred. This finding is consistent with previous studies, which reported a difficulty rate of 26.7%, 25.7%, and 2.9% respectively.26 However, the conversion rate was much higher in the present study (8.9% vs 3.3%).27 The conversion rate in contemporary studies ranged from 0.18% to 30%, with a minimal conversion rate in the present study. 21, 28
The conversion rate of cholecystitis (LC) has been reported to vary from 0.18% to 30%, with minimal conversion to open procedures in the present study.13 However, contemporary studies have reported rates ranging from 15.4% to 55.2%, with conversion rates ranging from 0% to 11%.20, 21, 22, 23 Tongyoo et al. reported a higher difficulty rate with 59.2% difficult and 15.1% very difficult procedures, and a conversion rate of 10.5%, which is one of the highest in contemporary studies reviewed.29 The present study encountered a low conversion rate, neither too high nor too low.
The study reveals that difficulty rates in LC are influenced by various factors, including patient, environment, and surgeon's skills. Differences in difficulty rates may be due to different criteria for defining difficulty, such as duration of surgery. High conversion rates may be due to surgical decision-making and patient profile. The study suggests that predictors of difficulty play a crucial role in understanding the complexity of LC procedures.30
The study used a comprehensive scoring system to predict difficulty in surgical procedures, with 22 cases predicted as difficult. The predictive scores were significantly higher in surgically difficult/very difficult (7.57±3.12) procedures compared to surgically easy procedures (2.07±1.90). The predictive efficacy of the scoring system was 90.5%, 95.7%, 86.4%, and 97.1%, with an accuracy of 94.4%. The rate of predicted difficulty in the study was close to the actual occurrence of difficult LCs (23.3%), which is contrary to previous studies that predicted difficulty in only 16% of cases but encountered actual difficulty in 34%.31 Veerank and Togale.32 predicted difficulty in 30% cases and confirmed intraoperative difficulty in 26.7% cases, with an accuracy of 90% and sensitivity and specificity of 86.4% and 75%, respectively. The study found the predictive scoring system to be more specific (95.7%) and less sensitive (90.5%), in agreement with previous studies.23, 33, 34 The high specificity and sensitivity of the predictive score align with Saad et al.'s findings, and the highly specific nature of the scoring system is similar to that reported by Ali et al.'s findings.
The study found that age >50 years and BMI >25 kg/m2 are significant predictors of difficulty in gastrointestinal cancer. This finding is consistent with previous studies, such as Mudgal et al., Nassar et al., Ali et al., and others.17, 26, 35 Other studies have also found age, male gender, BMI, and other demographic and patient-specific factors as significant predictors of difficulty in gastrointestinal cancer.26, 34, 36, 37
The study reveals that hospitalization history, comorbidity, and the presence of a supraumbilical abdominal scar are significantly associated with difficult LC. This finding is consistent with previous studies which also found comorbidities, chronic illnesses, diabetes mellitus, and hypertension as predictors of difficult LC.23, 28, 36, 37, 38
The study found that USG parameters such as gall bladder wall thickness >4 mm, palpability, presence of impacted stones, and mucocele/pyocele were significantly associated with difficult LC. These parameters are widely reported as significant predictors of difficult LC, and the findings of this study reinforce their usefulness as such predictors.39, 23, 24, 28, 29, 33, 34, 35, 36, 37, 38
The study found no significant association between laboratory/biochemical parameters and LC difficulty. Only a few studies have reported these parameters as significant predictors of difficult LC. One study found higher WBC and lower AST as significant predictors, while another found elevated S. amylase and higher WBC as associated with difficult LC.7, 18, 19 Most similar studies did not find a significant association between these parameters.
The study's limitation is the absence of novel difficulty markers like C-reactive protein, Fibrinogen, or other inflammatory markers. These markers could have improved the accuracy of predictive scores. The study emphasizes the importance of understanding the relevance of these scoring systems in individual settings and recommends enriching predictive scores with the inclusion of other variables. The findings highlight the need for further research on the role of these markers in determining difficulty rates.
Conclusion
The study evaluated 90 patients aged 15-70 years for difficult laparoscopic cholecystectomy procedures using a difficulty predicting scoring system. Factors like age, sex, hospitalization history, body mass index, abdominal scar presence, gall bladder palpability, leukocytosis, and sonographic parameters were used to predict difficulty. Intraoperative difficulty was classified based on time taken for surgery, bile stone spillage, and conversion to open procedure. The scoring system was highly accurate. Clinico-radiological factors predicting difficult laparoscopic cholecystectomy procedures included elevated BMI, acute cholecystitis history, pericholecystic fluid presence, and thickened gallbladder wall. Understanding these factors can improve preoperative planning, reduce conversion rates, and improve patient outcomes.
