Preoperative Prediction of Difficult Laparoscopic Cholecystectomy Using a Scoring System: A Prospective Cohort Study

Laparoscopic cholecystectomy (LC) is now considered the gold standard for the treatment of symptomatic cholelithiasis. However, conversion to open surgery is occasionally required due to intraoperative difficulties and complications. Early preoperative identification of difficult LC cases can be of help in surgical preparedness and patient counselling.

To evaluate the sensitivity, specificity, and predictive value of a preoperative scoring system in the prediction of difficult LC.

A prospective cohort study was conducted on 150 patients undergoing elective LC at Deen Dayal Upadhyay Hospital, New Delhi, India. Each patient was scored preoperatively based on age, sex, history of hospitalization, BMI, abdominal scars, palpable gallbladder, gallbladder wall thickness, pericholecystic fluid, and impacted stones based on the scoring system proposed by Randhawa and Pujahari. Intraoperative findings were recorded to classify cases as easy, difficult, or very difficult based on parameters that include time of surgery, bile/stone spillage, duct/artery injury, conversion to open surgery, difficulties in port access, Calot's triangle dissection, and gall bladder extraction. Statistical analysis included sensitivity, specificity, predictive values of the preoperative score, and logistic regression analysis.

The mean preoperative score was 2.55 ± 2.55. Intraoperatively, 72% of cases were classified as easy, 24.7% as difficult, and 3.3% as very difficult, with a conversion rate to open surgery of 3.3%. Thickened gallbladder wall (>4 mm), presence of pericholecystic fluid, impacted stones, and a BMI >27.5 were found to be significantly associated with increased operative difficulty (p < 0.05). The scoring system demonstrated a sensitivity of 57.14% and a specificity of 79.51%, while the positive predictive value and negative predictive value were 39% and 89%, respectively.

The proposed scoring system is a reliable, simple tool for predicting difficult LC preoperatively. Incorporation of this tool can assist in preoperative planning and improve surgical outcomes by better preparing and minimizing unexpected conversions.