Page 37 - World Journal of Laparoscopic Surgery

Preoperative Prediction of Difficult Laparoscopic Cholecystectomy
Table 1: Detailed layout of proposed and Randhawa et al. scoring Table 3: Criteria of final outcome on the basis of intra operative findings
systems Sl.
Proposed Randhawa No. Criteria Easy Difficult Conversion
Sl. scoring et al. scoring 1. Operative time <1 hour >1 hour –
No. Preoperative factors Findings system system 2. Adhesions Absent Present –
History findings 3. Bile/stone spillage Absent Present –
1. Age <50 years 0 0 4. Need for conversion to open – – Present
>50 years 1 1
2. Gender Female 0 0
Male 1 1 Statistical Analysis
3. History of hospitalization Absent 0 0 Statistical analyses were carried out using statistical software
Present 4 4 SPSS version 17. The data were presented as no. (%) for continuous
4. History of ERCP Absent 0 – variable and median (interquartile ranges) for categorical variable.
Present 2 – The preoperative predictive parameters were compared with
5. History of diabetes Absent 0 – results for difficult and easy using the Chi-square test for categorical
mellitus Present 1 – variable. Multivariate receiver operating characteristic (ROC) model
Clinical findings was performed to predict the result for difficulty. To analyze the
6. BMI <27.5 0 0 postoperative parameters prediction with the result, ROC analyses
were performed. The results were reported as a difference in
>27.5 2 2 proportion (95% CI). p value <0.05 was considered statistically
7. Previous abdominal Absent 0 0 significant.
surgery Present 1 2
8. Palpable gallbladder Absent 0 0 results
Present 1 1 Mean age of presentation was 46 years with 63 (62%) patients having
Ultrasonographic findings age <50 years and 39 (38%) having age >50 years. Surgery was easy
9. Gallbladder wall thickness <4 mm 0 0 in patients with age <50 years (73.4%) compared to patients with
>4 mm 2 2 age >50 where surgery was difficult (57.9%). This result was found
10. Pericholecystic fluid Absent 0 0 to be statistically significant (p value: 0.002). Out of 15 male patients
Present 1 1 nine (60%) had easy and six (40%) had difficult surgery, which on
11. Impacted gallbladder Absent 0 0 univariate analysis was not statistically significant (p value: 0.812).
calculus Present 1 1 Hospitalization for a history of acute cholecystitis was the most
12. Contracted gallbladder Absent 0 – significant preoperative predictor (p value <0.0001). Similarly, history
of diabetes mellitus was present in 13 patients (12%) and 11 (84.6%)
Present 1 – patients had difficult LC. It was a unique finding of our study where
Maximum score 18 15 history of diabetes mellitus came out to be a significant preoperative
predictor (p value: <0.0001). History of hypertension and dyspepsia did
not show any significant correlation to the predictability of difficult LC.
Palpable gallbladder was found in seven patients and all
Table 2: Preoperative prediction according to scoring done by both patients had difficult cholecystectomy. Patients who had a history
the scoring system
of abdominal surgery were 20 (19%), out of which only three cases
Sl. No. Predictive outcome Score (15%) had difficult LC, showing the result as insignificant but it must be
1. Easy 1–5 noted that most of these cases had infraumbilical scar for tubectomy
2. Difficult 6–10 or cesarean. There were five (4%) patients with a history of endoscopic
3. Need for conversion 11–18 retrograde cholangiopancreatography (ERCP) and four (80%) had
difficult cholecystectomy with p value <0.05. Mean BMI was 23.86.
BMI >27.5 was a significant preoperative factor with p value of 0.03.
Murphy’s sign was also found to be predictive with p value of 0.03.
structures namely Hartmann’s pouch, common bile duct, cystic All ultrasonographic findings included in the scoring system
duct, and cystic artery or lymph node to get familiar with the were significant namely gallbladder wall thickness (p value
anatomy. Then posterior to anterior peritoneal reflection around <0.0001), stone size >1 cm (0.002), pericholecystic fluid collection
Calot’s triangle was done clearing all the fat and clipping was (0.023), and contracted gallbladder (0.06). Common bile duct
done after only two structures are seen entering the gallbladder. diameter had no significant predictive value for difficult LC (Table 4).
LC was labeled as difficult on the basis of three intraoperative The ROC curve of multivariate analysis of all significant
parameters, i.e., operative time >1 hour, adhesions around the preoperative predictors showed area under curve of 97%. Positive
Calot’s with omentum or adjacent structure including duodenum predictive value and accuracy of Randhawa scoring system was 87.5
or transverse colon, and bile/stone spillage (Table 3). A master and 90.2% whereas that of modified scoring was 94.38 and 95.10%.
chart was prepared in the Microsoft Excel sheet including Sensitivity of both the scoring system was 95% with specificity of
all preoperative and postoperative parameters for statistical modified scoring greater (92%) than that of original scoring (76%)
analysis. (Fig. 1).

World Journal of Laparoscopic Surgery, Volume 14 Issue 1 (January–April 2021) 35