Clinical and financial impact of a 'difficult' laparoscopic cholecystectomy

Difficult intra-operative findings during laparoscopic cholecystectomy (LC) may lead to poor clinical outcomes. This study aimed to compare pre-operative, intra-operative, and post-operative variables of patients with 'straightforward' versus 'difficult' intra-operative findings and to assess the relationship between intra-operative findings and post-operative outcomes.

A retrospective cohort study of prospectively collected data from patients undergoing LC from August 1998 to December 2020 was conducted. Intra-operative findings were graded using the North Shore system, with Grade 1 or 2 classified as 'straightforward' LC and Grade 3 or 4 as 'difficult' LC. Logistic regression analyzed the relationship between poor post-operative outcomes and intra-operative findings.

Among 2633 patients, 2050 (78%) had 'straightforward' and 583 (22%) had 'difficult' intra-operative findings. Patients with 'difficult' findings were often younger, male, jaundiced, had higher Charlson Comorbidity Indexes (CCI), and were more likely to undergo urgent or semi-urgent operations in the public hospital. They experienced longer operation times, higher cholangiogram failure rates, more common bile duct explorations, longer hospital stays, higher conversion rates to open procedures, a greater risk of post-operative bile leaks, and higher rates of hospital readmission post-discharge. Higher CCI, pancreatitis, and intra-operative challenges such as CBD exploration and 'difficult' intra-operative findings were predictive of poor post-operative outcomes. The financial impact of 'difficult' intra-operative findings is significant.

There is an association between 'difficult' intra-operative findings and adverse clinical outcomes, confirming the negative financial impact of a less-than Textbook Outcome. This highlights the need to anticipate and make appropriate resources available for potentially challenging LCs.