Page 39 - World Journal of Laparoscopic Surgery

Preoperative Prediction of Difficult Laparoscopic Cholecystectomy

dIscussIon of these patients had delayed presentation due to neuropathy;
Cholelithiasis is a benign disease of the gallbladder where most therefore, more association with intraoperative adhesions was
encountered. In our study, we also found diabetes to be a strong
cases are asymptomatic or have mild symptoms. LC is the gold preoperative predictor of difficult LC.
standard procedure of choice for cholelithiasis and conducting Previous studies which have been done on the Randhawa et al.
a safe operation becomes the utmost priority for the operating scoring system concluded that it was more sensitive, less specific,
surgeon. Much work has been done to improve intraoperative and had 85–90% positive predictive value for the difficult cases
outcomes by following safe cholecystectomy protocol but not preoperatively. 3,13 Our study also found similar results however
much literature is available on the safe preoperative protocol. prediction done using a modified scoring system showed that the
Difficult LC requires preparation in form of operative skill, on specificity increased and positive predictive value also increased to
floor senior support, logical surgical steps, bailout procedures, 95%. This shows that simple modification can significantly increase
and most importantly a well-informed patient and attendants. the accuracy of the original scoring system. We found this scoring
Wrong selection of cases can result in devastating results both for system to be a simple bedside tool, which accurately predicted
the patient as well as for the operating surgeon. This justifies the difficult LC preoperatively in our setting.
importance of preoperative prediction of a difficult LC. This study had its limitation as it was a single-center study
Lee et al. and Hussain et al. in their study found age >50 years and validation in different hospital settings and populations may
7,8
as a risk factor for difficult LC. Rothman et al. also concluded in a be required for a further recommendation of this scoring system.
meta-analysis that there is association of higher rate of conversion A systemic review and meta-analysis of all the available scoring
9
in patients with age >60 years. Similarly, age >50 years was a methods would be the best way to remove these limitations.
significant preoperative risk factor in our study(p value – 0.01).
In studies done by Kanakala et al. and Rothman, male patients
had higher rate of conversion to open but it was not found to be conclusIon
associated with difficult LC in our study. 9,10 Many studies which Preoperative prediction helps in better preparation of the
studied preoperative risk factors for difficult LC did not find male challenges associated with difficult LC. An accurate and reliable
11
gender as an independent risk factor. History of hospitalization scoring system, therefore, comes handy for a surgical team in
for acute cholecystitis, palpable gallbladder, and BMI >27.5 is this situation. The scoring system that is proposed by the authors
among the most significant clinical parameters for predicting significantly increases the specificity and positive predictive value
difficult LC preoperatively. 2,3,12,13 In our study also these factors of the Randhawa et al. scoring system which has been validated
showed strong preoperative association in univariate analysis. by many studies previously. The proposed scoring system is
Though Murphy sign was significant preoperative factor in simple, easy to perform, requires no special investigation and can
univariate analysis, it did not show significant association in effectively categorize patients, so that the best expertise is available
multivariate analysis. Therefore, it was not considered as a risk when required and the patient is adequately counseled so that
factor for preoperative prediction. they are also prepared for various outcomes of otherwise a simple
Among the ultrasonographic findings, gallbladder wall procedure. Further evaluation in different clinical settings may be
thickness showed significant relation in our study, similar to studies required to validate the findings of this study.
done by Nachnani et al. and Randhawa et al. where wall thickness of
>4 mm had intraoperative difficulty in dissection of Calot’s due to clInIcAl sIgnIfIcAnce
adhesions and difficulty in grasping gallbladder. 2,14 Pericholecystic
fluid is found significant in our study with a higher incidence of The most important goal of a surgeon while performing a procedure
adhesions intraoperative. This is probably due to the fact that is to give the best and safest treatment to the patient. LC is the
pericholecystic fluid is found in cases of acute cholecystitis. Similarly gold standard treatment for patients with gallbladder disease but
impacted stones had a direct relation to difficult LC by creating the difficulties related to the procedure require both expertise in
difficulty in grasping the gallbladder which caused bile spillage. laparoscopic skills and the correct choice of bailout procedure to
Finding of the contracted gallbladder in ultrasonography (USG) prevent any major complication. The proposed scoring system can
was independent significant variable for difficult LC in our study effectively predict difficult LC preoperatively which would help in
and was associated with adhesions intraoperatively. Rothman et better preparation for a difficult scenario preoperatively. Patients
al. also found contracted gallbladder to be associated with higher can be optimally counseled preoperatively so that they are well
9
rate of conversions in their meta-analysis. Therefore, this factor was prepared for various outcomes of the procedure.
added to the scoring system proposed by the authors.
Other two factors which were added are history of ERCP and references
history of diabetes. Reinders et al. found in their study that history 1. Mc Kinley SK, Brunt LM, Schwaitzberg SD. Prevention of bile injury:
15
of pervious ERCP is a significant risk factor for a difficult LC. Fibrous the case for incorporating educational theories of expertise. Surg
adhesions around the Calot’s triangle due to the stent placed after Endosc 2014;28(12):3385–3391. DOI: 10.1007/s00464-014-3605-8.
ERCP cause disruption in the plane of dissection posing risk of bile 2. Randhawa JS, Pujahari AK. Preoperative prediction of difficult lap
duct injury, even in the hands of an experienced surgeon. These chole: a scoring method. Indian J Surg 2009;71(4):198–201. DOI:
patients also have a contracted gallbladder intraoperatively which 10.1007/s12262-009-0055-y.
further increases the complexity of an otherwise simple procedure. 3. Gupta N, Rajan G, Arora MP, et al. Validation of a scoring system
Timing of LC after ERCP has been found significant in a study by to predict a difficult laparoscopic cholecystectomy. Int J Surg
2013;11(9):1002–1006. DOI: 10.1016/j.ijsu.2013.05.037.
Aziret et al., showing early LC within 48 hours after ERCP leading to 4. Agrawal N, Singh S, Khichy S. Preoperative prediction of difficult
16
significant reduction in difficulty. Diabetes mellitus was a strong laparoscopic cholecystectomy: a scoring method. Niger J Surg
17
predictor for difficult LC in a study done by Aldachal et al. Most 2015;21(2):130–133. DOI: 10.4103/1117-6806.162567.
World Journal of Laparoscopic Surgery, Volume 14 Issue 1 (January–April 2021) 37