Page 46 - World Journal of Laparoscopic Surgery

Difficult Laparoscopic Cholecystectomy
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which were discussed earlier. In our study, we had no conversions et al., Corr et al., Lein and Huang, and Kama et al. have reported
to open cholecystectomy. All 100 patients have had a standard in their studies that there is an appreciable interconnection in
laparoscopic cholecystectomy. anticipating a difficult laparoscopic cholecystectomy if the stone in
In this study, we had a remarkable association with the thickness the GB measures more than or equal to 1 cm in diameter. Chindarkar
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of the GB wall. A total of 36 patients had an increased breadth. When et al. reported 40.0% of sensitivity, specificity of 92.5%, 72.7% of
we had a breadth of more than 4 mm, 27 (75%) of them had a difficult PPV, NPV of 75.5%, and 75% accuracy with p = 0.004. Our study
laparoscopic cholecystectomy and the rest 9 (25%) had an easy had a 52.5% of sensitivity, specificity of 76.7%, and PPV of 60.0%,
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laparoscopic cholecystectomy. Daradkeh et al., Lal et al., Carmody NPV of 70.8%, and 61% accuracy with p = 0.003 for the criterion if
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et al., Kreimer et al., and Corr et al. also reported in their respective GB calculus measurement in length is more than or equal to 1 cm.
studies that the GB wall thickness was the best ultrasonic parameter Other two criterion in preoperative ultrasound, namely, the
to predict a difficult laparoscopic cholecystectomy. size of distension of the GB of more than or equal to 5 cm and the
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Chindarkar et al. and Dinkel et al. reported the sensitivity of CBD caliber size of more than or equal to 6 mm was found to have
65 and 66.7%, specificity of 97 and 94.1%, positive predictive value no statistical significance in predicting a difficult laparoscopic
(PPV) of 92.9 and 84.2%, negative predictive value (NPV) of 84.8, and cholecystectomy. This is a contrast discovery we found to the study
85.3% for escalating in the breadth of the wall of the GB of more than made by Chindarkar et al., Lal et al., Corr et al., and Daradkeh et al.
4 mm as a criterion for operative difficulty. Whereas in this study, we They have published that they noticed a moderate interrelation in
had a sensitivity of 67.5%, specificity of 85.0%, PPV of 75.0%, NPV anticipating a difficult laparoscopic cholecystectomy.
of 79.7%, and an accuracy of 78.0% for escalating in the breadth of Several studies have attempted to form a scoring to predict a
the wall of the GB of greater than 4 mm as a criterion to anticipate a difficult laparoscopic cholecystectomy preoperatively. However,
difficult laparoscopic cholecystectomy, respectively, with p = 0.000. most of these studies are complex and use large number of
Next to increased thickness, the further notable statistically determining factors. These studies are difficult to adapt and use in
significant criterion was the GB stone impacted at the neck. Out of regular day-to-day practice. 22–25 In our studies, the scoring method
20 cases that had stone impacted and adhered at the GB neck, 15 was made in such a way that it is easy to follow and to use on
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cases were found to be difficult. Daradkeh et al., Santambrogio regular day-to-day practice. In the study reported by Chindarkar
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et al., and Randhawa and Pujahari have reported that when we et al., they had a 92.86% of sensitivity, 97.5% of specificity, PPV of
had a case where the stone is firmly attached to the neck of the GB 65.0%, NPV of 97.5%, and accuracy of 86.66% for the preoperative
there are more chances that the case will be having a difficulty in ultrasound score of more than or equal to 4. Whereas in this study,
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dissection during surgery. Chindarkar et al. and Akhter et al. have the sensitivity was 100.0%, specificity was 71.43%, PPV of 40.0%,
reported that there is a firm association with the impaction of the NPV of 100.0%, and 76.0% accuracy for preoperative ultrasound
stone at the neck of the GB to anticipate a difficult laparoscopic scores more than or equal to 4 as a criterion to predict a difficult
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cholecystectomy. Chindarkar et al. reported a sensitivity of 40%, laparoscopic cholecystectomy with p = 0.000.
specificity of 100%, PPV of 100%, NPV of 76.9%, and 80% accuracy The difficulties we faced in our study intraoperatively are the
for the stone impaction at the GB neck. presence of dense peri GB adhesions and frozen Calot’s triangle.
The chief difficulty observed during the surgery is when the There was a minimal tear in the GB during dissection which
calculi get adhered to the neck and making it difficult to hold and accounted for bile and stone spillage. In our study, there was no injury
grasp with laparoscopic instruments. It slows down and restricts made to the hepatic duct, CBD, and hepatic artery. We did not have
retraction and the dissection of the Calot’s triangle. There is also bleeding that hindered the visual field, buried or intrahepatic GB.
mucocele formation due to mucus collection with in turn makes the In this study, there were no conversions to open cholecystectomy.
GB to be distended and tense. In our study, we found a sensitivity All 100 patients have had a standard laparoscopic cholecystectomy.
of 37.5%, specificity of 91.7%, PPV of 75.0%, NPV of 68.8%, and 67% Our observation made from the study agrees with other studies by
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accuracy with p = 0.000. Corr et al., Fried et al., Chindarkar et al., Santambrogio et al.,
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Our study also discovered that there is an appreciable and Daradkeh et al., that the preoperative ultrasonography finding
interconnection between the existence of pericholecystic collection can help in predicting a difficult laparoscopic cholecystectomy.
in anticipating a difficult laparoscopic cholecystectomy. In our study,
out of 100 patients, 39 of them had the presence of pericholecystic conclusIon
fluid collection in their preoperative ultrasound. Among those 39 Overall critical complication rates seen in a standard laparoscopic
of them, 23 patients had a difficult laparoscopic cholecystectomy. cholecystectomy are more and seen frequently when compared
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In the study done by Chindarkar et al. and Nidoni et al., they to traditional open cholecystectomy. Most of these complications
have reported that presence of pericholecystic collection have a are made due to the difficulty faced during the surgery. Therefore,
significant correlation with a difficult laparoscopic cholecystectomy. it would be helpful to have some tools to recognize a difficult
They also reported a sensitivity of 50.0 and 70%, specificity of 97.5 laparoscopic cholecystectomy preoperatively. Determining the
and 91.76%, PPV of 90.9 and 33.33%, NPV of 79.6 and 98.11%, and factors that can predict a difficult laparoscopic cholecystectomy
accuracy of 81.7 and 73.33%, respectively. In our study, we had a preoperatively based on ultrasound findings was the aim of our study.
result of 57.5% of sensitivity, specificity of 73.3%, PPV of 59.0%, NPV The primary objective of our study is to validate a cut-off score from
of 72.1%, and accuracy of 67% with the p = 0.002. the ultrasonography formulated scoring method in identifying a
Few studies have reported that there is a statistical significance difficult laparoscopic cholecystectomy. Finding the most notable and
between the sizes of the GB calculus with the difficult laparoscopy remarkable criterion in ultrasonography which is interrelated with a
cholecystectomy. In this study, 35 patients had their calculus size difficult laparoscopic cholecystectomy was our secondary objective.
more than or equal to 1 cm. Among those 35 patients, 21 patients A total of 100 patients who are satisfied to our inclusion criteria
(60%) had a difficult laparoscopic cholecystectomy. Chindarkar who were admitted for laparoscopic cholecystectomy were included
232 World Journal of Laparoscopic Surgery, Volume 15 Issue 3 (September–December 2022)