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RESEARCH ARTICLE
Intraoperative Predictors of Difficult Laparoscopic

Cholecystectomy: AMU Scoring System

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Mohammad S Akhtar , Parwez Alam , Yasir Alvi , Isna R Khan , Syed AA Rizvi , Mohammad H Raza 6
AbstrAct
Introduction: With laparoscopy being the surgeon’s first choice even in difficult cholecystectomy, a need to objectively grade intraoperative
difficulty during laparoscopic cholecystectomy (LC) is gaining popularity. The study was done to design a scoring system to predict the difficult
outcome during intraoperative LC.
Materials and methods: The study was done at the General Surgery Department in a tertiary level hospital among patients undergoing LC. The
procedures that exceeded 70 minutes in duration and/or converted to open were considered the difficult LC. To develop the predictive score,
an association of various factors with difficult cholecystectomy was identified by performing multiple logistic regression analysis, and receiver
operating characteristic (ROC) curve was plotted to estimate the cutoff value for the scoring system.
Results: We recruited 200 patients in this study, out of which 85 had difficult cholecystectomy procedures. Among all intraoperative predictors,
adhesions, gallbladder (GB) condition, Calot’s triangle status and abnormality, and the presence of pericholecystic fluid were associated with
a difficult LC. Based on the odds ratio, a new scoring system was designed with a score ranging from 0 to 25. The grading score was created as
easy (0–5) and difficult (6 or above) based on the intraoperative factors. At a cutoff score of 6, this scoring system had a sensitivity and specificity
of 87.1 and 88.7%, respectively.
Conclusion: This study demonstrates that an intraoperative scoring system can predict the difficult outcome of LC. This can help in minimizing
the complication and conversion to open cholecystectomy, especially relevant for funds-limited settings like India.
Keywords: Cholecystectomy, Conversion to open and Calot’s triangle, Laparoscopic, Operative scoring system.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1454

IntroductIon 1,2,4–6 Department of Surgery, Jawaharlal Nehru Medical College and
Laparoscopic cholecystectomy (LC) has transformed the whole Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
approach to the treatment of symptomatic cholelithiasis. In the 3 Department of Community Medicine, Jawaharlal Nehru Medical
beginning, surgeons felt comfortable operating only the simple College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh,
gallbladders (GB) by LC, but with the increase in expertise and India
newer armory, it is also becoming surgeon’s first choice even in Corresponding Author: Parwez Alam, Department of Surgery, Jawaharlal
difficult cholecystectomy. However, LC can be difficult in various Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh,
situations, especially in a surgeon’s early career, which makes Uttar Pradesh, India, Phone: +91 9045974632, e-mail: parwez786amu@
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them a little stressed. Various problem faced includes difficulty gmail.com
in creating pneumoperitoneum, accessing peritoneal cavity, How to cite this article: Akhtar MS, Alam P, Alvi Y, et al. Intraoperative
releasing adhesions, identifying the anatomy, anatomical variations, Predictors of Difficult Laparoscopic Cholecystectomy: AMU Scoring
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and extracting the GB. It can be more difficult in males than in System. World J Lap Surg 2021;14(2):114–118.
females who are also more commonly diagnosed with cholelithiasis Source of support: Nil

requiring surgery. 4,5 Conflict of interest: None
The term difficult cholecystectomy refers to multiple
technical intraoperative difficulties that increase the risk of
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complications and significantly prolong the operative time.
Difficult LC is related to an increased incidence of conversion to MAterIAls And Methods
open cholecystectomy, probably because of greater difficulty
in operation, and therefore, greater is a likelihood of conversion Study Design and Population
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to open technique. At the same time, the level of difficulty may We did a cross-sectional study over a period of 1 year from July
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vary with the skill and experience of the surgeon. While many 2015 to June 2016. The study population included all patients
preoperative LC assessments are available, there are only a few consulting the surgery outpatient department, Jawaharlal Nehru
intraoperative laparoscopic surgeries difficultly predicting the Medical College, Aligarh, and subsequently diagnosed as a case of
criteria, leaving a gap in studying important factors that can help cholelithiasis. This hospital is a tertiary referral center and is one of
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in preventing complications beforehand. Thus, this study was the largest hospitals in the northwest part of the state Uttar Pradesh.
done to develop a scoring system to predict the difficult outcome A total of 200 patients were diagnosed as cholelithiasis; as per
during intraoperative LC. the standard protocol, they were included in the study. Exclusion

© Jaypee Brothers Medical Publishers. 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
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