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ORIGINAL ARTICLE
Comparison of Intraoperative Findings with Ultrasonographic

Scoring for Predicting Difficult Laparoscopic Cholecystectomy

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Satendra Kumar , Sanjay K Saroj , Raghunath S More , Soham Roy , Amit ND Dwivedi , Satyendra K Tiwary 6
AbstrAct
Introduction: Nowadays laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstone disease (GSD). Prediction of
“difficult laparoscopic cholecystectomy” (DLC) may decrease morbidity and mortality as well as reduce the average cost of therapy. At present,
very few scoring systems are available to predict the degree of difficulty during surgery.
Aim and objective: To compare the outcome of intraoperative findings with preoperating scoring to predict DLC.
Materials and methods: Two-hundred and nine patients were having GSD, operated by a single experienced surgeon in 2-year duration. Various
preoperative predictors and intraoperative parameters of DLC were used for scoring and categorizing the difficulties, into (0–5), (6–10), and
(10–15) as early, difficult, and very difficult surgical procedures, respectively.
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Result: History of hospitalization for acute cholecystitis, overweight with BMI ≥27.5 kg/m , palpable gallbladder, wall thickness >4 mm, and
impacted stone were the most accurate preoperative predictors of DLC in the age-group of above 50 years. Statistically, a significant association
was determined by comparing preoperative evaluation with the intraoperative outcome.
Conclusion: The preoperative and intraoperative scoring system can be helpful for assessment, experience, and decision-making. These scoring
systems deserve a large-scale prospective study for validation.
Keywords: Acute cholecystitis, Gallstone disease, Intraoperative scoring.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1477

IntroductIon 1,2,4,6 Department of General Surgery, Institute of Medical Sciences,
In India, the prevalence of gallstone disease is estimated at Banaras Hindu University, Varanasi, Uttar Pradesh, India
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around 4%. About 1–2% of asymptomatic patients may develop 3 Department of Anatomy, Banaras Hindu University, Varanasi, Uttar
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symptoms that require cholecystectomy per year. Laparoscopic Pradesh, India
cholecystectomy (LC) is a procedure with about 0.5% mortality 5 Department of Radiodiagnosis and Imaging, Institute of Medical
and 10% morbidity. 3 Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
Abdominal ultrasonography (USG) is sensitive and specific Corresponding Author: Satendra Kumar, Department of General
between 84 and 99% to diagnose extrahepatic biliary diseases Surgery, Institute of Medical Sciences, Banaras Hindu University,
and detect gallstones size between 1.5 and 2 mm in diameter. Varanasi, Uttar Pradesh, India, Phone: +91 9838673200, e-mail:
Preoperative USG is functional in accessing surgical difficulties or skumar79bhu@gmail.com
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even the possibility of laparotomic conversion. Existing scores How to cite this article: Kumar S, Saroj SK, More RS, et al. Comparison
use as subjective scales to identify high-risk patients, derive risk- of Intraoperative Findings with Ultrasonographic Scoring for
assessment models, and evaluate the risk of conversion from Predicting Difficult Laparoscopic Cholecystectomy. World J Lap Surg
laparoscopic to open procedure. However, conversion is not a 2021;14(3):166–170.
good reflection of operative difficulty. In contrast, operative time Source of support: Nil
is considered as reproducible criteria of the encountered difficulty Conflict of interest: None
for a surgeon. 6
The study aimed to compare the preoperative predictive
factors that determine difficult LC (preoperative scoring) with coagulopathies, and end-stage liver disease, and gallbladder
intraoperative parameters (intraoperative scoring). anomaly. After written informed consent, all patients underwent
elective LC by an experienced laparoscopic surgeon.
History of the patients, clinical examination, and laboratory
MAterIAls And Methods and radiological investigations were the factor to diagnose the
A prospective observational study was done in Department of GSD. The preoperative anticipating factors for LC were as similar
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General Surgery, Institute of Medical Sciences, Banaras Hindu as defined in the preoperative scoring system. In addition, while
University (UP) with a sample size of 209 patients of both sexes doing LC, various intraoperative parameters were calculated which
(age 14–74 years) having symptomatic gallstone disease (GSD). were used for categorizing and grading LC as easy, difficult, and
All patients were admitted to the SS Hospital, Banaras Hindu very difficult as shown in Table 1. In each patient, the scores (both
University, Varanasi, from September 2016 to July 2018. Exclusion preoperative and intraoperative) were compared for predicting
criteria were LC performed with other combined laparoscopic difficult laparoscopic cholecystectomy (DLC). LC was carried out
procedures in the same setting, LC with common bile duct using CO pneumoperitoneum with 12–13 mm Hg pressure and
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exploration, contraindications to LC, like cardiopulmonary disease, standard four-port manner (two 10 mm and two 5 mm). Total

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