A clinical study to determine predictive factors for difficult laparoscopic cholecystectomy

Abstract

The technique of laparoscopic cholecystectomy (LC) has been standardized and it has become a routine and safe operation. However, there are numerous conditions which make the operation difficult necessitating conversion to open surgery. Preoperative prediction of a difficult cholecystectomy and the risk of conversion is of great help both to the patient who can be counseled appropriately pre-operatively and the surgeon who can also schedule his time and team accordingly. This prospective cross-sectional study was conducted on 118 patients undergoing laparoscopic cholecystectomy in Department of General Surgery, Aditya Birla Memorial Hospital, Chinchwad, Pune, over a period of 18 months from October 2015 to March 2017, to evaluate and correlate the clinical, biochemical and ultrasonography findings with the operative findings for anticipating difficult laparoscopic cholecystectomy. The parameters which were studied are age ≥ 60 years, sex, BMI > 30, history of (h/o) previous upper abdominal surgery, history of gall stone related complications, history of prior biliary intervention, biochemical parameters like Hb, TLC and LFT levels, gall bladder wall thickness (≥ 4 mm), pericholecystic collection, gall bladder size (contracted or distended gall bladder), stone impaction at neck/cystic duct and stone size > 1 cm. The operative parameters taken to assess the difficulty of the LC were total time taken to operate from the insertion of the trocar to the extraction of the gall bladder (more than 90 minutes), change of procedure to subtotal cholecystectomy and conversion to OC. Our study results show that significant predictors for difficult LC are increasing age of patients, h/o gall stone related complications, h/o prior biliary intervention, raised TLC and deranged LFT levels, GB wall thickness ≥ 4 mm, pericholecystic fluid collection, tensely distended/contracted GB and stone size > 1cm. However factors like sex of patient, BMI, history of previous upper abdominal surgery, haemoglobin levels and stone impacted at neck of gall bladder showed no significant relation with operative difficulty.