Preoperative prediction of difficult laparoscopic cholecystectomy: an institutional cross-sectional study

Laparoscopic cholecystectomy (LC), a minimally invasive surgical procedure has largely replaced the open technique for cholecystectomies since the early 1990s and is the treatment of choice for the management of symptomatic gall stone diseases. It has been proved to be an effective and safe procedure in both elective and emergency conditions. However, conversion to open surgery in 2%-10% becomes inevitable. Moreover, surgeons assess difficulty intraoperatively. Preoperative prediction, vital for planning, relies on accurate scoring systems for surgical complexity. In this study, we aimed to evaluate the prognostic utility of a preoperative scoring system and identify predictive variables for LC complexity in a tertiary care institution.

A cross-sectional analytical study was conducted among patients where the preoperative grading system stratified patients into three risk groups: low risk (0-1 score), intermediate risk (2-6 scores), and high risk (7-19 scores). The intraoperative Nassar grading categorized patients into four difficulty levels, ranging from Grade 1 (least difficult) to Grade 4 (most difficult). Dichotomization was adopted to provide a clinically useful distinction between "easy" and "difficult" cases, reflecting real-world operative decision-making. This preoperative scoring scale was employed for assessment and analyzed using SPSS-25.

Among 405 consenting participants, 41.2% were males, and 58.8% were females. The mean age was 50.49 ± 14.56 years (Mean ± SD), ranging from 17 to 80. The majority had primary diagnosis of biliary colic (31.4%) followed by chronic cholecystitis (31.1%). Thickened gallbladder walls were noted in 40.5%, common bile duct dilation in 17.5%, with 19.5% undergoing preoperative endoscopic retrograde cholangiopancreatography. Anticipated difficult LC was estimated in 158 patients. Intraoperative assessment, utilizing the Nassar grading guideline, revealed that 72.8% of cases were categorized as easy, while 27.2% were classified as difficult.

This prospective study demonstrates a clear association between various risk factors and challenging LC. Overview data collection, encompassing demographic, laboratory, and radiological information, supported analytical assessments. However, reliance on a single tertiary care center is a notable limitation, underscoring the need for multicenter studies to validate and identify additional predictors of complexity in LC.