Page 36 - World Journal of Laparoscopic Surgery

ORIGINAL ARTICLE
Simple and Reliable Scoring System to Predict Difficult

Laparoscopic Cholecystectomy Preoperatively

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Pradeep Goyal , Shanmugavel Muthuraman , Saurabh Sharma 3
AbstrAct
Aim and objective: To validate the efficacy of proposed scoring system compared to the Randhawa scoring system in prediction of difficult
laparoscopic cholecystectomy (LC) preoperatively.
Materials and methods: A prospective study was conducted including 102 patients who underwent LC for symptomatic cholelithiasis.
Preoperatively a score was given to the patient according to both scoring systems. Final outcome was decided on intraoperative findings
of operative time, adhesions, and bile spillage. Univariate and multivariate analyses of preoperative factors were done. Receiver operating
characteristic (ROC) curves of both the scoring system were compared, and the results were reported as a difference in proportion (95% CI).
p value <0.05 was considered as statistically significant.
Results: The specificity and positive predictive value of the modified scoring system were 92 and 95.1% which was higher than Randhawa
scoring system, i.e., 76 and 87.5%. Area under ROC curve was also more in modified scoring system. Also, univariate analysis found age >50 years,
history of hospitalization, previous endoscopic retrograde cholangiopancreatography, diabetes mellitus, palpable gallbladder, gallbladder wall
thickness, and contracted gallbladder on ultrasound to be statistically significant factors.
Conclusion: The proposed modified scoring system significantly increases the specificity and positive predictive value of the Randhawa scoring
system. This scoring system is easy to perform, require no additional investigation and can effectively categorize patient where LC will be difficult.
Clinical significance: The proposed scoring system can effectively predict difficult preoperatively which would help in better preoperative
preparation by the surgical team for a difficult laparoscopic cholecystectomy. Patients can be optimally counseled preoperatively so that they
are well prepared for various outcomes of the procedure.
Keywords: Difficult cholecystectomy, Laparoscopic cholecystectomy, Prediction, Preoperative, Scoring system, Simple.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1444

IntroductIon 1–3 Department of General Surgery, Maharishi Markandeshwer Medical
Laparoscopic cholecystectomy (LC) is the most common minimal College and Hospital, Solan, Himachal Pradesh, India
invasive procedure performed by general surgeons around Corresponding Author: Saurabh Sharma, Department of General
the globe. Early recovery, shorter hospital stay, and minimal Surgery, Maharishi Markandeshwer Medical College and Hospital,
postoperative discomfort after the surgery are among the few Solan, Himachal Pradesh, India, Phone: +91 09418173024, e-mail:
reasons which make this surgery a gold standard treatment for 100rbhs@gmail.com
symptomatic cholelithiasis. Although the complication rate of LC How to cite this article: Goyal P, Muthuraman S, Sharma S. Simple
ranges from 0.1 to 6%, which might look small, the actual number and Reliable Scoring System to Predict Difficult Laparoscopic
of complications is both large and is a cause of significant morbidity Cholecystectomy Preoperatively. World J Lap Surg 2021;14(1):34–38.
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to the patient. Most complications, which are avoidable, are caused Source of support: Nil
due to the lack of adequate preparation for a difficult operation. Conflict of interest: None
Randhawa et al. proposed a scoring system for preoperative
prediction of difficult LC, which has been validated by many studies
with variable results. 2–4 To improve the predictive value of this anesthesia, had comorbidity (except diabetes and hypertension),
scoring system, very few modifications have been proposed; these bleeding diathesis, operation which were prolonged due to
5,6
are complicated and too much elaborated. Here we propose nontechnical reasons (light or instrument failure), and patient not
a simple modified scoring system that can be done bedside giving consent for the study. Patients were admitted a day before
preoperatively and compare its efficacy to the original scoring surgery, and a detailed history and examination were done along
system. with documentation of the investigations. A score was given to each
patient preoperatively according to the modified scoring system as
well as the Randhawa scoring system (Table 1) to label each patient
MAterIAls And Methods as easy or difficult LC. In both scoring systems, a score of <5 was
A prospective study was conducted between July 2019 and considered easy, 6 to 10 was considered difficult, and >11 as need
December 2019 enrolling a total 102 patients who underwent LC for for conversion to open (Table 2).
symptomatic cholelithiasis. All patients were operated by a single Standard four-port LC was performed with pneumoperitoneum
surgeon, with experience of more than five years in laparoscopic of 12 mm Hg. A standard intraoperative protocol was followed
surgery. Exclusion criteria had those patients who were unfit for in each patient starting with bile duct timeout to visualize the

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