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Intraoperative Finding and Ultrasonographic Scoring for Predicting DLC
Table 1: Intraoperative scoring and difficulty levels—our criteria Table 2: Preoperative predictive factors of DLC (preoperative scoring
system), according to Randhawa and Pujahari 7
Intraoperative parameters Scores Grading
Time taken <60 minutes, thin GB wall having 0–5 Easy Parameters Score No. (%)
no/<50% omental adhesion, no stone in the Age ≤50 0 144 (68.90)
Hartman’s pouch, no bile spillage, no injury >50 1 65 (31.10)
to duct or artery Sex Female 0 144 (68.90)
Time taken 60–120 minutes, thick GB wall 6–10 Difficult Male 1 65 (31.10)
having >50% omental adhesion/buried GB,
stone impacted in the Hartman’s pouch, and/ History of No 0 136 (65.10)
or bile or stone spillage and/or injury to duct hospitalization for Yes 4 73 (34.90)
acute cholecystitis
Time taken >120 minutes or conversion 11–15 Very difficult
BMI <25 + 25–27.5 0–1 148 (70.81)
operation time was considered from the first port site incision to >27.5 2 61 (29.19)
the last port closure. The data were statistically analyzed using Abdominal scar No 0 125 (59.80)
SPSS 16.0. Receiver operating characteristic (ROC) curve analysis Infraumbilical + 1–2 84 (40.20)
was used to estimate difficulty. supraumbilical
Palpable gallbladder No 0 130 (62.20)
Declaration of Patients Consent Yes 1 79 (37.80)
The authors certify that consent forms have been obtained from Wall thickness <4 mm 0 148 (70.82)
each patient. In that form, the patients have given their consent for
their general and other clinical information to be reported in the ≥4 mm 2 61 (29.18)
journal. The patients understand that their personal information Pericholecystic No 0 157 (75.11)
will not be published and due efforts will be made to conceal collection Yes 1 52 (24.89)
their identity. Impacted stone No 0 142 (67.94)
Yes 1 67 (32.06)
results Easy 0–5
A total of 209 patients with symptomatic gallstone disease Difficult 6–10
undergoing LC were included in this study. The patient characteristics Very difficult 11–15
are shown in Table 2. Out of 209 patients, 111 (53.1%) patients were
found easy during surgery, while 86 (41.1%) patients were found
difficult. Five patients had a duration of surgery >120 minutes while dIscussIon
7 patients were converted to open, due to dense adhesion with Difficult laparoscopic cholecystectomies have an inbuilt risk of
difficulty in delineating anatomy of Calot’s triangle, so these 12 (5.8%) conversion, due to dense adhesions of the gallbladder or inability
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patients were considered as very difficult (Table 3). to delineate the anatomy. Conversion to open cholecystectomy is
Through preoperative evaluation, 98 (46.88%) patients were considered a wise decision of the operating surgeon. Age is a risk
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predicted to be difficult/very difficult while 95 (45.45%) surgery factor for difficult GB surgery. Lee et al. found that for difficult LC,
of patients was difficult/very difficult, whereas 3 (1.43%) patients late-adulthood (>50 years) age-group considered as significant
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turned out to be on an easy surgery. However, the cases predicted risk factor. The study established a significant association
to be easy on preoperative evaluation were 111 (53.11%) patients, between the difficulty level of surgery in bivariate analysis and
of which 108 (51.67%) patients were easy, whereas 3 (1.43%) the late-adulthood age-group in both preoperative (p <0.001)
patients turned out to be difficult/very difficult on surgery, and by and intraoperative (p <0.001) outcomes. An independent risk for
comparing preoperative and intraoperative evaluation (p <0.001), conversion is controversial in male. However, the study did not
statistically significant association was found (Table 3). find any significant association between different sex and difficulty
On comparing the preoperative outcome with risk factors in level of surgery through bivariate analysis in preoperative and
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predicting difficult LC, acute cholecystitis, overweight with BMI intraoperative outcomes, likewise Liu et al. findings.
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>27.5 kg/m , palpable GB, ≥4 mm of wall thickness, and obstructed Bhondave et al. and Nidoni et al. reveal that prior attacks
stones were found as significant in bivariate analysis, whereas of acute cholecystitis were a significant predictor of difficult LC
other factors, such as sex, abdominal scar, and pericholecystic (p = 0.0002). 12,13
collection, were found insignificant in above 50 years of age- BMI >27.5 was found to be a significant risk factor in
group. On comparing the intraoperative outcome with risk factors, preoperative and intraoperative outcomes, in concordance with
we found almost similar observations as shown in Table 4. the study by Randhawa and Pujahari and Naik and Kailas. 7,14 Hence,
The study evaluated the ROC curves for prediction of the study concludes that obesity is considered a risk factor for
intraoperative outcome through the preoperative score at cutoff difficult LC.
point of 5.5 and area under the curve (AUC) of 0.974 [95% CI: Previous abdominal surgery may have caused adhesions
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(0.95–0.99); p <0.001], and showed 96.9 and 97.3% of sensitivity and between the viscera and omentum or abdominal wall. Bhondave
specificity, respectively (Table 5, Fig. 1). In addition, the ROC curve et al. and Gupta et al. scars over the abdomen were statistically
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for very difficult vs difficult cases at cutoff point of 8.5 and AUC of not significant and did not contribute to difficult LC (p = 0.149).
0.782 (95% CI: 0.60–0.96; p = 0.002) showed the sensitivity of 75% The abdominal scar was found as statistically insignificant while
and specificity of 62.0%, as shown in Table 5 and Figures 2 and 3. palpable GB was found to be predictor of difficult LC, clinically

World Journal of Laparoscopic Surgery, Volume 14 Issue 3 (September–December 2021) 167