Natl. J. Physiol. Pharm. Pharmacol. (2025), Vol. 15(2): 197-203

Original Research

10.5455/NJPPP.2025.v15.i2.14

An observational study of patients with cholelithiasis, undergoing laparoscopic cholecystectomy to predict it is difficulty using preoperative scoring system

Nirav Patel, Darshan Patel* and Shaunak Chacha

Department of Surgery, GCS Medical College, Hospital and Research Center, Ahmedabad, India

*Corresponding Author: : Darshan Patel. Department of Surgery, GCS Medical College, Hospital and Research Center, Ahmedabad, India. Email: darshan2794 [at] gmail.com

Submitted: 20/11/2024 Accepted: 19/01/2025 Published: 28/02/2025

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Abstract

Objectives: This study aimed to validate whether predictive factors can predict difficult laparoscopic cholecystectomy (LC).

Method: This observational prospective study was conducted at GCS Medical College, Hospital & Research Center over a period of 2 years, from July 2022 to 2024.

The studied predictive factors were

• Age ≥50 years
• Male sex
• Body mass index (BMI) > 27.5 kg/m²
• History of hospitalization for acute cholecystitis
• History of abdominal surgery
• Palpable gallbladder (GB)
• Ultrasound (USG) findings:
  • Pericholecystic fluid presence
  • Impacted stones
  • GB wall thickness > 4 mm

Detailed history, examination, and risk factor assessment were performed on all 100 subjects. Surgery was performed using CO₂ pneumoperitoneum at a pressure of 10 mmHg with two 5- and two 10-mm ports. The timing was recorded from the first incision at the port site until the last port closure. All patients received standard postoperative care and follow-up.

Results: The duration of surgery was significantly influenced by factors such as gender (p=0.015), previous abdominal surgery (p=0.034), GB wall thickness (p < 0.0001), past history of cholecystitis, and the presence of impacted stones on USG (p=0.014). Conversely, factors like age, BMI, pericardial fluid, and clinically palpable GB had no significant impact, as observed in the study.

Conclusion: The use of a preoperative scoring system to predict difficult LC is effective, offering advantages such as reliance on commonly performed tests, no need for specialized equipment, and ease of understanding and implementation.

Keywords: Gallbladder, Laparoscopic cholecystectomy, Difficult cholecystectomy, Pre-operative assessment of gallbladder operation.

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Introduction

Gallstone disease affects 3%–20% of the global population. The majority of gallstones are asymptomatic, with symptoms like biliary colic, jaundice, and fever occurring in a minority of patients. Symptoms typically emerge when a stone obstructs the cystic duct (Schwartz and Brunicardi, 2010).

Gallstones are often detected incidentally via imaging methods, such as ultrasound (USG), computed tomography (CT), HIDA, abdominal radiography, or during surgery. Laboratory tests, including liver function tests and total leukocyte counts, are also valuable for diagnosing gallbladder (GB) disease. Approximately 3% of patients with gallstones develop symptoms annually (Schwartz and Brunicardi, 2010).

Cholecystectomy (GB removal) is the treatment of choice for symptomatic and, in some cases, asymptomatic gallstone disease, unless the patient is at high risk for surgery under general anesthesia. Among cholecystectomy procedures, laparoscopic cholecystectomy (LC) is considered the gold standard. Since its introduction, LC has revolutionized minimally invasive surgery over a span of two decades. With increased experience, surgeons began performing more complex procedures, including in high-risk patients, leading to higher complication rates and an increased rate of conversion to open cholecystectomy (OC) (Schrenk et al., 1998; Nachnani and Supe, 2005).

Worldwide, 3%–10% of LC require conversion to open surgery. LC offers advantages such as reduced morbidity, shorter hospital stays, better cosmesis, and quicker recovery times. However, not all LCs can be completed laparoscopically, and conversion to OC is necessary in certain cases (Schwartz and Brunicardi, 2010; Williams and O’Connell, 2023).

Several factors contribute to the conversion of LC to OC, including acute cholecystitis, anatomical anomalies, extensive fibrosis, advanced age, male sex, prior upper abdominal surgeries, pancreatitis, inadequate laparoscopic instruments, GB wall thickness >3 mm, presence of pericholecystic fluid, and intraoperative complications, such as uncontrolled bleeding or injury to internal organs (Schrenk et al., 1998; Randhawa and Pujahari, 2009).

Conversion from laparoscopic to open surgery is associated with a set of risks, including an increased risk of surgical site and respiratory infection, and prolonged hospital stay. Consequently, several studies have focused on predicting difficult LC and the need for conversion to OC (Schrenk et al., 1998; Suryawanshi et al., 2014).

Accurately assessing a patient’s risk of conversion to OC based on preoperative factors can improve patient preparation, operating room efficiency, and patient safety by anticipating difficulties, ensuring proper surgical team instructions, and minimizing time spent on conversion. Although various scoring systems have been developed to predict conversion to OC, these systems have not been widely incorporated into surgical practice for various reasons. Risk factors are listed in Table 1. Table 2 shows the PreOperative Scoring System for predicting the difficulty of LC (Williams and O’Connell, 2023). Table 3 shows easy versus difficult criteria according to time taken and complications arising from the operative procedure (Randhawa and Pujahari, 2009).

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Materials and Methods

This observational prospective study was conducted at GCS Medical College, Hospital & Research Center over a period of 2 years, from July 2022 to 2024.

Inclusion criteria

- Patients aged 18 years and older.

- Patients diagnosed with symptomatic cholelithiasis undergoing elective LC who are willing to be part of the study.

Exclusion criteria

- Patients younger than 18 years;

and patients undergoing cholecystectomy as part of another surgical procedure.

- Patients with choledocholithiasis

A review of patients undergoing elective LC due to symptomatic cholelithiasis in our hospital 24 months before the study period was completed. The sample size was calculated with a 95% confidence interval and 10% margin of error using the formula n=z²× p × (1 - p) / e2 (assuming p=0.5 therefore q=0.5) as 97. Hence, the first 100 patients satisfying the inclusion criteria were enrolled in the study.

The study was approved by the Institutional Ethics Committee. After the outpatient department workup, scores were assigned based on history, clinical examination, and USG findings prior to surgery.

Scores were categorized as follows: 0–5 (easy), 6–10 (difficult), and 11–15 (very difficult).

Surgery was performed using CO₂ pneumoperitoneum at a pressure of 10 mmHg with two 5-mm and two 10-mm ports. The timing was recorded from the first incision at the port site until the last port closure. All patients received standard postoperative care and follow-up.

Definition of Variables

1. Independent variables

• a. Patient characteristics
• Gender
• Age (evaluated as a continuous variable)
• Body mass index (BMI) (evaluated as a continuous variable; a BMI > 27.5 indicates obesity)

b. Medical history

• Past hospitalization for cholecystitis
• Palpable GB
• History of upper abdominal surgery

c. USG findings

• GB wall thickness (classified as thick if > 4 vs. < 4 mm)
• Presence of pericholecystic fluid collection

2. Outcome variables

Difficult LC was assessed based on the duration of surgery in minutes, which was defined as the time from the first port site incision to the closure of the port sites. This was evaluated as a continuous variable.

Statistical analysis

The analysis of various preoperative risk factors and their relationship with outcome variables was performed using the independent t-test. A p-value of <0.05 was considered statistically significant.

Surgical technique

The surgeon’s preference determines whether a 5- or 10-mm laparoscope is introduced into the abdomen through the periumbilical port, providing visual exploration of the abdominal cavity. An angled laparoscope (30° or 45°) is preferred over a 0° scope for better visualization.

The patient was positioned in reverse Trendelenburg at 30° with a 15° left tilt. This position helps move the colon and duodenum away from the liver edge, allowing for better visualization of the falciform ligament and both liver lobes. Typically, the GB protrudes beyond the liver edge.

Table 1. Various preoperative risk factors.

Table 2. PreOperative scoring system for predicting the difficulty of laparoscopic cholecystectomy.

Table 3. Easy vs difficult criteria according to time taken and complications arising from the operative procedure.

Two small subcostal ports are placed under direct vision. A 5-mm trocar is inserted along the right anterior axillary line between the 12th rib and iliac crest. Another 5-mm port is then placed in the right subcostal region along the midclavicular line. Grasping forceps are used to secure the GB, while the assistant handles the lateral forceps to elevate the liver by grasping the fundus.

A fourth working port is inserted through a midline epigastric incision, typically 5 cm below the xiphoid process, although its exact placement depends on the GB’s location and the size of the medial segment of the left liver lobe.

Port placement and dissection: The dissecting forceps are directed toward the GB neck, aligning the laparoscope parallel to the cystic duct. The fundus is elevated using lateral forceps, and the GB is then mobilized. Adhesions between the GB and surrounding structures (e.g., omentum, hepatic flexure, and duodenum) are avascular and can be bluntly lysed. The infundibulum of the GB is dissected from the cystic duct, with care taken to avoid injury to the common bile duct (CBD).

The Rouvière’s sulcus, located on the undersurface of the right liver lobe, helps identify the position of the right posterior sectoral pedicle. By maintaining dissection ventral to the sulcus and the line joining the roof of the sulcus to the base of segment IV (R4U line), the risk of CBD injury is minimized.

Dissection begins 4–5 cm proximal to the GB’s neck, progressing distally using a modified “top-down” technique. The goal is to liberate the GB from its bed and create a window beneath it to expose the cystic duct and artery. Once identified, these structures are separated from surrounding tissue, and the cystic duct is clipped, and divided. If necessary, the distal cystic duct may be ligated using an endoloop.

After securing the cystic duct and artery, the GB is detached from the fossa via electrocautery and blunt dissection. The dissection continues until the GB is connected by only a thin bridge of tissue, at which point the final attachments are divided. Hemostasis is checked, and the GB is removed through the abdominal wall, often using an endobag for specimens with large stone burdens or perforation. In cases with minimal stone burden, stone removal can be accomplished through the subxiphoid or umbilical port site.

All ports were closed after ensuring adequate hemostasis.

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Results

Risk factor no. 1: age

• Gallstone disease was found most common in the fourth and sixth decades in our study. The oldest patient was 82 years old, and the youngest patient was 19 years. Gallstone disease is more common in females than males.

Risk factor no. 2: male gender

• In the study population, females were the predominant sex who underwent LC at 72% and males accounted for 28% of the cases.

Risk factor no. 3: BMI

Risk factor no. 4: history of abdominal surgery

• 25% of the patients had a history of upper abdominal surgery, of which 8 had a supraumbilical scar, 17 had an infraumbilical scar, and 75% had no history of upper abdominal surgery.

Risk factor no. 5:USG findings of pericholecystic collection.

Risk factor no. 6: USG findings for GB wall thickness.

Risk factor no. 7: USG findings for impacted stones.

Risk Factor no. 8: Past history of hospitalization for cholecystitis

Risk factor no. 9: palpable GB.

• In the present study: Male sex, history of upper abdominal surgery, history of previous hospitalization, incidence of impacted stone, and GB wall thickness are statistically significant.
• Out of 100 patients planned for LC, 18 patients had a history of ERCP and stenting, 31 patients had bile/stone spillage, 5 Patients had an injury to the duct/artery, and 4 converted to OC.

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Discussion

LC is the gold standard procedure for treating symptomatic GB disease, replacing OC as the preferred treatment. LC offers numerous advantages over open surgery, including reduced postoperative pain, quicker recovery times, lower complication rates, shorter hospital stays, and improved cosmetic outcomes. However, LC can sometimes pose challenges that may prolong the surgery, including difficulty creating pneumoperitoneum, accessing the peritoneal cavity, managing adhesions around the GB, retrieving the GB, and dealing with stone or bile spillage. In certain cases, conversion to open surgery may be required. Therefore, identifying preoperative factors that predict potential difficulties would be invaluable for the surgeon.

Numerous studies have sought to identify preoperative factors that can predict LC difficulty. These factors include sex, BMI, history of pancreatitis or cholecystitis, prior upper abdominal surgeries, and USG findings, such as GB wall thickness, pericholecystic fluid collection, and advanced age.

Age

In the present study, 48% of patients with extended surgery duration were >50 years old. For patients aged > 50 years, the average surgical time was 97.45 ± 32.85 minutes, whereas for those <50, it was 88.19 ± 35.06 minutes. Older age was associated with more challenging surgeries, but the difference was not statistically significant (p=0.17). In a study conducted by Raza and Venkata (2019) Even though as the age advances the difficulty in surgery increases with age, the result was not statistically significant.

Gender

The current study found that females comprised 72% of the patients undergoing LC, whereas males accounted for 28%. The mean duration of surgery for male patients was 105.82 ± 34.18 minutes, whereas for female patients it was 87.51 ± 32.99 minutes. This difference was statistically significant (p=0.015). Severe fibrosis and anatomical changes due to inflammation are more common in men; hence, LC is more difficult in these patients. In a study by Nachnani and Supe (2005) male sex was identified as a significant risk factor for predicting difficult LC, with an odds ratio of 3.429.

BMI

In the present study, patients with a BMI >27.5 kg/m² had an average surgery duration of 103.77 ± 31.9 minutes, whereas those with a BMI of 27.5 kg/m² had a mean surgery duration of 90.19 ± 34.34 minutes. However, the difference between the two groups was not statistically significant (p=0.127). A study by Raza and Venkata (2019) also found that BMI did not have a statistically significant effect on surgical difficulty (p=0.6). In contrast, Nachnani and Supe (2005) reported that obese patients faced significantly more difficulty in accessing the peritoneal cavity, and BMI was a significant predictor for conversion to open surgery.

Past history of hospitalization for cholecystitis

In the present study, 56 patients had a history of hospitalization for cholecystitis, with an average surgical duration of 108.56 ± 32.4 minutes. In contrast, 44 patients without cholecystitis had an average surgery time of 71.53 ± 23.5 minutes, and the difference was statistically significant (p < 0.0001). A study by Nachnani and Supe (2005) found similar results, in which patients with a history of hospitalization for cholecystitis had a significantly longer surgery time (55.46 ± 10.99 vs. 48.32 ± 8.83, p=0.03).

Past history of upper abdominal surgery

In the present study, patients with a history of upper abdominal surgeries (mainly tubal ligation scars) had an average surgery duration of 105.12 ± 32.27 minutes, compared to 88.48 ± 33.97 minutes in patients without such a history. The difference between the two groups was statistically significant (p=0.034). In a study conducted by Jagdish Nachnani and Supe (2005) history of previous upper abdominal surgery is a predictor (p < 0.05) for difficult LC, as difficulties might arise during adhesiolysis, creation of pneumoperitoneum, and while gaining ample exposure to the operating field.

USG findings of GB wall thickness

In this study, patients with GB wall thickness >4 mm had an average surgical duration of 129.38 ± 21.09 minutes. In comparison, patients with normal GB wall thickness had an average surgical duration of 87.14 ± 32.36 minutes. The difference was statistically significant (p=0.027). Raza and Venkata (2019) also found that GB wall thickness >4 mm predicted surgical difficulty, with a significant result (p=0.01). In a study conducted by Nachnani and Supe (2005) increased GB wall thickness was the most common reason for conversion from laparoscopic to OC because the inability to delineate the anatomy and dissection of the GB bed was difficult (p < 0.05).

USG findings of pericholecystic fluid

In the present study, patients with pericholecystic fluid had a mean surgical duration of 122 ± 31.11 minutes, compared to 92.04 ± 34.11 minutes for those without pericholecystic fluid. However, the difference was not statistically significant (p=0.221).

Palpable GB

In the present study, patients with clinically palpable GB who underwent surgery had a mean duration of 150 minutes, whereas those without palpable GB had a mean duration of surgery was 92.06 ± 33.84 minutes.

There is only one case of palpable GB in the present study. This may be strongly associated with difficult LC, but a higher number of cases are required to prove the association.

In a study conducted by Raza and Venkata (2019) clinically GB was palpable in 14 patients. Intraoperatively distended GB, mucocele with impacted stone, adhesions between the GB, omentum, and stomach in few cases. The palpable GB be strongly significant in predicting difficult LC with (p < 0.01).

Randhawa and Pujahari (2009) in their study, authors gave more score to palpable GB was found to be strongly significant in predicting difficult LC (p=0.001).

USG findings of impacted stone

In the present study, patients with one on USG had a mean surgical duration of 109.25 ± 34.59 minutes, whereas those without an impacted stone had an average duration of 88.48 ± 32.98 minutes. This difference was statistically significant (p=0.014). An impacted stone causes distension of the GB, making it difficult to grasp and making dissection difficult, similar to a thickened GB. Raza and Venkata (2019) also found that impacted stones, particularly at the neck of the GB, were strongly predictive of surgical difficulty, with a p-value of <0.001.

The limitation of this study was that it was limited to a single center. A large, multi-centric, randomized control study would be needed to assess the role of various risk factors in detail. Also, being a teaching institute, a single surgeon would not be performing all surgeries and hence, variation in experience and skill of operating surgeons also needs to be taken into consideration.

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Conclusion

In conclusion, the duration of LC is significantly influenced by factors such as sex, previous abdominal surgery, GB wall thickness, previous history of cholecystitis, and the presence of impacted stones on USG. These factors directly contribute to extended surgical times, indicating the complexity of the procedure.

Conversely, other factors like age, BMI, pericholecystic fluid, and clinically palpable GB, did not show a significant impact on the surgery duration or yielded inconclusive results, likely due to the limited data available. These findings underscore the multifaceted nature of surgical duration and highlight the need to consider individual patient characteristics when planning and managing surgery.

The use of a preoperative scoring system to predict difficult LC is effective. However, further randomized, prospective, multicentric studies with larger sample sizes are required to validate the efficiency of the scoring system.

Nonetheless, it has clear advantages, including the ability to rely on commonly performed tests, the need for no specialized equipment, and ease of implementation. This scoring system is particularly beneficial in teaching institutions like GCS Hospital, where surgeons with varying levels of experience perform LCs.

By assigning surgery based on predicted difficulty, this system ensures better preparedness, including support from senior surgeons, anesthetists, operating room staff, and necessary equipment, which can help minimize intraoperative conversion time. Furthermore, this scoring approach improves preoperative patient counseling, providing clear insights into potential surgical outcomes based on the patient score.

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References

Nachnani, J. and Supe, A. 2005. Preoperative prediction of difficult laparoscopic cholecystectomy using clinical and ultrasonographic parameters. Indian J. Gastroenterol. 24, 16–18.

Randhawa, J.S. and Pujahari, A.K. 2009. Preoperative prediction of difficult lap chole: a scoring method. Indian J. Surg. 71, 198–201; doi:10.1007/s12262-009- 0055-y

Raza, M. and Venkata, R.M. 2019. Predicting difficulty in laparoscopic cholecystectomy preoperatively using a scoring system. Int. Surg. J. 6, 957–962.

Schrenk, P., Woisetschläger, R., Rieger, R. and Wayand, W.U. 1998. A diagnostic score to predict the difficulty of laparoscopic cholecystectomy from preoperative variables. Surg. Endoscopy. 12(2), 148–150.

Schwartz, S.I. and Brunicardi, F.C. 2010. Schwartz’s principles of surgery, 9th edition. New York, NY: McGraw Hill Professional.

Suryawanshi, P., Nandakishor, S. and Upasna, B. 2014. USG in gall bladder disease prediction of difficult laparoscopic cholecystectomy. IJSR 3, 2012–2015.

Williams, N. and O’Connell, P.R. 2023. Bailey & love’s short practice of surgery, 28th edition. Boca Raton, FL: CRC Press.