Page 42 - World Journal of Laparoscopic Surgery

Preoperative Scoring System to Predict Difficult LC
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et al. also reported that previous history of hospitalization, GB spilled gallstones. The final patient was a 60-year-old lady with
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thickness >3 mm, and BMI >30 kg/m are good predictors of the previous hospitalization for cholecystitis, an infra-abdominal scar,
level of difficulty in LC. GB wall thickness of >4 mm in size, pericholecystic collection, and
In my study, no cases were converted into open. This is a large an impacted stone. The preoperative score was 10, but the patient
variation as compared to 27.9% (Oymaci et al., 2014), 19 cases underwent a 140 minutes surgery and also had intraoperative
(17%) by Randhawa et al. in 2009, 11.4% (Nachnani et al. in 2005), complications of iatrogenic injury to the gallbladder.
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5.7% (Bakos et al., 2008), 5.3% (Ishizaki et al., 2006), and 0.36% The scoring system used in our study is extremely effective in
(Singh et al., 2005). This variation can be attributed to the surgeon predicting the difficulty of the LC with very high sensitivity. The
to surgeon variations, the underlying prognostic determinants of ability to accurately predict and discuss the other determinants
the individual, lack of uniform evaluating system, and difference of difficulty in LC is limited by the small sample size. The focus of
in sample size. The experience of the surgeons and time spent in future research should be on finding out the exact relationship
perfecting the surgical techniques help in achieving a low rate of between the individual variables and the difficulty of the surgical
complications. procedure.
In this study, there is a positive correlation between the
operative outcome and the preoperative total score of the summAry
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participants (χ = 74.52, df = 4, p <0.001*). There is a positive
correlation between preoperative grade and operative outcome This study aimed to study a preoperative scoring system to
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(χ = 43.51, df = 1, p <0.001*). There is also a positive correlation predict difficult laparoscopic cholecystectomies. A prospective
between the preoperative score and duration of surgery (r = 0.752, observational study was performed using 66 subjects. All the
p <0.001*) and the length of hospital stay (r = 0.788, p <0.001*). patients had a thorough history taken and a proper clinical
Finally, there is a positive correlation between the preoperative examination, and all of them underwent ultrasound abdomen
2
score and the intraoperative complications (χ = 14.75, df = 1, and pelvis scanning. Depending on history (age, sex, H/o
p <0.001*). The validation of the scoring system is limited, owing to hospitalization for attacks of cholecystitis), clinical examination
the small sample size. On the other hand, individual bias in surgery (BMI, abdominal scar, and palpable gallbladder), and USG
is avoided by following a single surgeon. An individual surgeon has abdomen and pelvis (wall thickness, pericholecystic collection
been followed for the duration of our study, and the results reflect and impacted stone) parameters, all the subjects were awarded a
the outcomes of surgery performed by that individual surgeon. preoperative score of 0–15. A score of 0–5 was predicted to be an
A balance has been maintained to avoid the bias from different easy cholecystectomy (time taken <60 minutes, no bile spillage,
surgeons and to get an adequate sample size. and no injury to duct or artery), a score of 6–10 was predicted to be
Nine cases did not correlate with the correct prediction of a difficult cholecystectomy (time taken 60–120 minutes, bile/stone
outcome from scoring. Three patients with a preoperative score spillage, injury to duct, and no conversion), and a score of 11–15 was
of 5 had difficult cholecystectomies. One of them was a 65-year- predicted to be a very difficult cholecystectomy (time taken >120
old female with a BMI of 28.50 with infraumbilical incision and minutes or conversion to open).
impacted stone on sonologic examination. It was predicted as easy It was seen that the scoring system evaluated in our study
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with a score of 5, but the duration extended to 70 minutes making is a reliable, sturdy, and useful benchmark (χ = 43.51, df = 1,
it difficult. Another two cases were of females with a BMI of >27.5 p <0.001*) to predict difficult cases. It was excellent in predicting the
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kg/m with infraumbilical incision and gallbladder wall thickness intraoperative complications (85% of patients with complications
of >4 mm. They were predicted as easy with a score of 5, but the had a preoperative grade of difficult), the overall difficulty of the
duration extended to 85 and 90 minutes, making it difficult. This procedure being performed, and also the duration of hospital stay.
is attributed to the presence of thickly adherent gallbladder in the
bladder fossa. conclusIon
Three patients with a preoperative score between 6 and 10 This study was aimed to develop a scoring method for difficult LC
underwent easy laparoscopic cholecystectomies. One was male of and to correlate preoperative predictive factors with intraoperative
55 years of age, with a BMI between 25 and 27.5, an infra-abdominar difficulty in laparoscopic cholecystectomy, intraoperative
scar (lower midline) and a wall thickness on USG abdomen and complications, and duration of hospital stay, by assessing various
pelvis of >4 mm. The preoperative score in this patient was 6, preoperative predictors (history/clinical/imaging). The procedure
but the operation took only 50 minutes making it easy. The other of choice for management of symptomatic gallstone disease is
2 males were below the age of 50, who had previous history of laparoscopic cholecystectomy.
hospitalization for cholecystitis, one patient had GB wall >4 mm in Here are the conclusions we have drawn from the study: The
thickness and one had a BMI of 26. The preoperative grades were preoperative scoring system devised is excellent at predicting
7 and 6, but both patients underwent easy cholecystectomies the intraoperative difficulties encountered by surgeons while
(55 and 50 minutes). performing laparoscopic cholecystectomy with a sensitivity of
Three patients with a preoperative score between 6 and 88.9% and a specificity of 92.3%. The scoring system also predicted
10 underwent very difficult laparoscopic cholecystectomies intraoperative complications with a specificity of 94.2% when
as opposed to just difficult as predicted. Two of these patients the score is >7. There was also a very strong correlation between
were males above the age of 50 and with a BMI of >27.5. Both the preoperative score and the duration of surgery (r = 0.752,
had supraumbilical scars, a GB wall thickness of >4 mm, and p <0.001) and also between the preoperative score and the
pericholecystic collections. Both had a preoperative score of 9 but duration of hospital stay (r = 0.788, p <0.001). Surgeons encounter
underwent operations exceeding 120 minutes, with one patient difficulty when there were dense adhesions in the calot’s triangle,
having iatrogenic perforation of gallbladder and another having fibrotic and contracted GB, acutely inflamed, and pericholecystic

138 World Journal of Laparoscopic Surgery, Volume 15 Issue 2 (May–August 2022)