Difficult Laparoscopic Cholecystectomy Predictors and its Significance: Our Experience

Laparoscopic cholecystectomy (LC) has become the procedure of choice for the management of symptomatic gallstone disease. In LC, the surgeons encountered difficulties with acutely inflamed or gangrenous gallbladder (GB), dense adhesions at Calot's triangle, fibrotic and contracted GB, and cholecystoenteric fistula. Depending on the difficulty faced during the surgery, the outcome of LC may vary from abandoning the procedure or partial cholecystectomy to conversion into open cholecystectomy. Complications related to biliary tract or adjoining structures or vessels may also occur. Our aim was to assess the different preoperative factors in patients of cholelithiasis and ascertain the validity of the scoring system devised by Randhawa and Pujahari in preoperatively predicting the difficult LC in our hospital scenario.

This hospital-based observational study was conducted in the Department of General Surgery for a period of 2 years. All diagnosed cases of cholelithiasis admitted for elective LC during the study period in our hospital were included in the study.

In total, 154 patients, aged≥50 years, history of hospitalization for acute cholecystitis (AC), body mass index of 25 kg/m² and more, abdominal scar, palpable GB, GB wall thickness ≥4 mm, pericholecystic collection, impacted stone found to be significant factors to predict difficult LC preoperatively. Endoscopic retrograde cholangiopancreatography and pancreatitis were found as independent risk factor for difficult LC.

We recommend that the scoring system should be regularly used as a protocol for predicting difficulty levels preoperatively in LC. It can help to decide the surgical approach, counsel the patients, and reduce the complication rate, rate of conversion, and overall medical cost. The scoring system proposed by Randhawa and Pujahari is effective but has some lacunae.