Page 14 - World Journal of Laparoscopic Surgery

Peroperative Scoring System for Difficult Lap Cholecystectomy
difficult cholecystectomy is defined as a score ≥5 that is included cholecystectomy. Various operative findings were scored from
in our study. 11 5 to 10 as per the operative predictors for difficult laparoscopic
Intraoperative findings were assessed on the basis of five key cholecystectomy (Table 3).
aspects which includes: 11
The Score of 5–7 (Severe Degree of Difficulty)
• Appearance of gallbladder and amount of adhesions; Out of 50 patients, 16 patients (34%) with chronic calculous
• Distension/contraction of the gallbladder; cholecystitis were considered in the study and a severe degree
• Access to the peritoneal cavity; of difficulty was encountered with a mean score of 5 during
• Any local/septic complications; laparoscopic cholecystectomy. The duration of the surgery was
• Time taken to dissect the Calot’s triangle.
between 45 and 60 minutes.
All the patients were accessed by the intraoperative scoring Total 28 (56%) cases of acute calculus cholecystitis were
system and evaluated for the amount of complexity and results operated and a severe amount of complexity was faced with mean
of the surgery were studied by the above scoring system scoring of 6. About 60–70 minutes was the time taken to complete
(Tables 1 and 2). 11 all laparoscopic cholecystectomies in the above patients.
In 3 (6%) cases of mucocele, the gallbladder was operated and a
result severe degree of difficulty was encountered with a mean score of 7
This study was carried out on 50 cases of difficult laparoscopic in these cases in performing laparoscopic cholecystectomy. About
cholecystectomy among them 45 patients were female (90%) 54–81 minutes was the time taken to complete all laparoscopic
and males were 5 (10%). Most females were 22–55 years of age. cholecystectomies in the above patients. In one case cystic duct
Males were between 48 and 70 years. All of them are evaluated stump was transfixed with vicryl (3’0) by laparoscopic intracorporeal
according to scoring and categorized into difficult laparoscopic suturing.

Table 1: Scoring according to peroperative finding The Score of 8–10 (Extreme Degree of Difficulty)
Two of the patients were found to havie empyema of the gall
Cholecystitis scoring according to peroperative finding Score bladder and an extreme degree of difficulty was found in those
Appearance cases with a mean score of 8. These cases were converted to
Adhesions <50% of GB 1 open cholecystectomy. The inability to dissect Calot’s triangle
Adhesions >50% but GB buried 2 with dense adhesion is the indication for conversion into open
Completely buried GB 3 (max) surgery. To prevent damage to the bile duct in one case subtotal
Distension/contraction cholecystectomy was done.
Distended GB or contracted shrilled GB 1 In one more case of gangrenous gall bladder with irresectable
Inability to grasp without decompression 1 Calot’s triangle and dense adhesions, we found an extreme
Stone >1 cm impacted in Hartmann’s pouch 1 amount of complexity with a score of 8 and was converted
Access to open.
These three cases of extreme difficulty were required to be
BMI >30 1 converted into open surgeries even after the usage of advanced
Adhesions from previous surgery limiting surgery 1 energy devices (ligasure scalpel) to prevent bile duct injury.
Sepsis and complications Among all 50 cases, we have completed laparoscopic
Free bile or pus outside the gallbladder 1 cholecystectomy successfully in 47 patients with a severe amount
Fistula 1 of complexity. While three cases with an extreme amount of
Total possible 10 complexity were converted to open surgery.

dIscussIon
Table 2: Grading of difficulty Due to unpredictable intraoperative findings, laparoscopic
Grading of degree of difficulty according to peroperative finding cholecystectomy is one of the most surprising operations in general
12
Mild <2 surgery. An unexpected amount of complexity of surgery was
13
Moderate 2–4 found in some cases while in some cases it is very easy. In about
Severe 5–7 6–35% of cases, laparoscopy cholecystectomy is converted to
14
open. In this study, 6% of patients were also converted to open.
Extreme 8–10
Inability to dissect the Calot’s triangle due to dense adhesions and
Table 3: Overview of whole study
Mean duration Number of cases
Degree of difficulty (according Mean severity Number of surgery converted into open Peroperative
to peroperative scoring system) Diagnosis score of cases (in minutes) cholecystectomy complications
Severe (score: 5–7) Chronic calculous cholecystitis 5 16 45–60 0 0
Acute calculous cholecystitis 6 28 55–70 0 0
Mucocele of gall bladder 7 3 60–80 0 0
Extreme (score: 8–10) Empyema of gall bladder 8 2 100–120 2 0
Gangrenous gall bladder 8 1 125 1 0

12 World Journal of Laparoscopic Surgery, Volume 15 Issue 1 (January–April 2022)