Difficulty Of Laparoscopic Cholecystectomy Research Articles

New Proposed Classification of Difficulty in Laparoscopic Cholecystectomy.

Background: Difficult laparoscopic cholecystectomy (LC) has been challenging for surgeons. Randhawa's system used operative time, complications, and conversion to define three difficulty grades. However, using fixed numbers of operative time as dividers among three groups might not be applicable universally. This study aimed to propose new classification with more flexible parameters. Methods: This retrospective cohort study was conducted with patients who underwent LC because of gallstone-related diseases between January 2017 and December 2021 at Thammasat University Hospital. The exclusion criteria were (1) emergent LC for acute cholecystitis, (2) other procedures performed in the same setting of LC, (3) incomplete information, and (4) LC converted to open cholecystectomy. Patients were categorized into three groups using Randhawa's classification. Thereafter, new classification using mean and standard deviation was applied to reclassify patients into three new groups. The comparison between two grading results was performed to prove the advantage of new classification. Results: Total of 523 patients who underwent LC were included with median age 59.3 years old and 60.8% female. By Randhawa classification, proportions of easy, difficult, and very difficult groups were 39%, 53.7%, and 7.3%, respectively. Then, the new operative-time dividers among three groups were changed from 60 and 120 minutes to mean and mean + 2SD, respectively. Reclassified three difficult groups were 38.9%, 57.1%, and 4%. The comparison demonstrated new classification as more flexible and more compatible with each individual surgeon. Conclusions: New surgeon-referenced grading system of difficult LC included surgeon's factors, not only unfavorable operative findings. This classification should be more flexible than the previous criterion-referenced one. Thai Clinical Trials Registry at https://www.thaiclinicaltrials.org with Number TCTR20220426003.

Preoperative difficulty factors in delayed laparoscopic cholecystectomy: Tokyo Guidelines 2018 surgical difficulty score analysis.

Tokyo Guidelines 2018 (TG18) recommend early laparoscopic cholecystectomy (LC) for low-risk acute cholecystitis (AC); however, some patients undergo delayed LC (DLC) after conservative treatment. DLC, influenced by chronic inflammation, is a difficult procedure. Previous studies on LC difficulty lacked objective measures. Recently, TG18 introduced a novel 25 findings difficulty score, which objectively assesses intraoperative factors. The purpose of this study was to use the difficulty score proposed in TG18 to identify and investigate the predictors of preoperative high-difficulty cases of DLC for AC. We retrospectively reviewed 100 patients with DLC after conservative AC treatment. The surgical difficulty of DLC was evaluated using a difficulty score. Based on previous studies, the highest scores in each category were categorized as grades A-C. The severity of AC was mild in 51 patients and moderate in 49. Surgical outcomes revealed a distribution of difficulty scores, with grade C indicating high difficulty, showing significant differences in operative time, blood loss, achieving a critical view of safety, bailout procedures, and postoperative hospital stay compared with grades A and B. Regarding the preoperative risk factors, multivariate analysis identified age >61 years (p = .008), body mass index >27.0 kg/m2 (p = .007), and gallbladder wall thickness >6.2 mm (p = .001) as independent risk factors for grade C in DLC. The difficulty score proposed in TG18 provides an objective framework for evaluating surgical difficulty, allowing for more accurate risk assessments and improved preoperative planning in DLC for AC.

Scale and Safety: Analyzing the Association Between Intraoperative Difficulty and Achieving the Critical View of Safety in Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy (LC) is the preferred method for gallstone removal, but bile duct injuries remain a concern. Achieving the critical view of safety (CVS) is pivotal in preventing such injuries. The aim of this study was to compare the rates of difficult LC in those with CVS achieved compared to those with CVS not achieved. We performed a single-center prospective study on all patients with ultrasound-confirmed symptomatic gallstones. Patients were excluded if they refused to consent or if they underwent LC for indications other than gallstone disease. Patients were stratified into two groups as CVS not achieved and CVS achieved groups and compared for outcomes. Our primary outcome was the rate of intraoperative difficulty on the modified Nassar scale (MNS). Statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY). We included 70 patients who underwent LC for gallstones (CVS not achieved = 24 and CVS achieved = 46). The mean (SD) age was 42.2 (12.3) years, and 73.5% were females. The mean (SD) weight in our study cohort was 74.1 (10.9) kg, and there was no difference between the two groups in terms of the baseline demographic characteristics, disease characteristics, and comorbid conditions (p > 0.05). On univariate analyses, achieving CVS was associated with lower rates of higher-grade operative difficulty on the MNS and lower rates of length of stay of more than one day. Achieving CVS is associated with easy LC based on significantly lower Nassar scores. These findings highlight the role of the MNS in the successful identification of the operative difficulty of LC and its correlation with achieving CVS.

Pre-operative Predictive Factors for Difficult Laparoscopic Cholecystectomy at Tertiary Care Centre

INTRODUCTION Gallstones are present in 10 to 15% of general population and asymptomatic in more than 80% cases. Laparoscopic cholecystectomy is a gold standard treatment for cholelithiasis. The rate of conversion from laparoscopic cholecystectomy to open is about 1-13%. Predicting the difficulty of laparoscopic cholecystectomy is essential to optimize patient outcomes. The levels of difficulties during laparoscopic cholecystectomy can be predicated based on certain preoperative clinical, laboratory or radiological parameters. The main aim of the study was to find out the pre-operative predictive factors for difficult laparoscopic cholecystectomy at a tertiary care centre. MATERIAL AND METHODS This was an observational cross-sectional study that included sixty nine patients who underwent elective laparoscopic cholecys- tectomy in UCMS. Preoperative predictive parameters such as age, gender, BMI, previous abdominal surgery, gallbladder condition, and ultrasound findings were assessed. A scoring system developed by Randhawa and Pujahari was used to predict difficulty in laparoscopic cholecystectomy, and intraoperative criteria were used to categorize cases as easy or difficult. RESULTS History of acute cholecystitis (p=0.026), previous abdominal scar (p=0.024), thick gallbladder wall (p=0.012), impacted stone (p=0.057), pericholecystic fluid collection (p<0.001) and increased BMI were considered as the significant factors that predict difficult laparoscopic cholecystectomy. Sensitivity and specificity for easy - difficult cut off of the scoring method were 75.6% and 67.16%, respectively, with the area under the ROC curve being 0.524. CONCLUSION The difficult laparoscopic cholecystectomy and conversion to open surgery can be predicted preoperatively based on preoperative scoring system.

Evaluation of the difficulty of laparoscopic cholecystectomy during COVID-19 pandemic using externally validated prediction models: A retrospective cohort study

IntroductionDuring the COVID-19 pandemic, elective surgeries suspension, led to delayed hospital visits for non-emergent diseases like acute cholecystitis. Although nonsurgical treatment was successful in numerous cases, there are some warnings about the progression of the disease to more advanced stages for laparoscopy. In this study, we aimed to find out if COVID-19 had adverse effects on the difficulty of laparoscopic cholecystectomy (LC). MethodsIn a retrospective cohort study at a referral center for minimally-invasive surgeries, medical records from February 2019 to February 2020 (before the pandemic) and from February 2020 until 2021 (during the outbreak) were reviewed and various data were extracted. Using two different preoperative scoring systems, we estimated the rate of difficulty of LCs, and the results compared to each other with appropriate statistical methods. ResultsA total of 531 LCs were performed. Pre-COVID and post-COVID patients had a mean age of 46 ± 15 and 44 ± 14 years old, respectively, and less than 35 % of patients in each group were males. LCs decreased notably during the pandemic (161 vs. 369, p < 0.001). Besides, elective surgeries were reduced in this period (36.6 % vs. 55.7 %, p < 0.001). Despite no significant changes in operation duration (123 ± 42 vs. 129 ± 40, p = 0.16), scoring models revealed a remarkable change in difficulties. ConclusionUsing two well-established scoring models, we concluded that LCs were done with less difficulty during that period. However, there was a remarkable decrease in elective surgeries, and higher volume studies are required to confirm our results.

PREDICTION OF DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY BASED ON ULTRASONOGRAPHIC FINDINGS

Objectives: The objective of the study is to the role of pre-operative ultrasonography (USG) abdomen to find difficulty in laparoscopic cholecystectomy. Methods: It was a prospective observational study conducted in the Department of General Surgery, Government Medical College, Kottayam, for a period of 12 months after obtaining approval from the Institutional Review Board and Ethical Committee. A total of 94 patients who underwent elective laparoscopic cholecystectomy were randomly allotted and their pre-operative ultrasound was assessed. Pre-operative predictability of difficult laparoscopic cholecystectomy based on USG was studied. Results: Out of 78 difficult laparoscopic cholecystectomies, 71 cases were predicted to have intra-operative difficulty with pre-operative ultrasound as per total time taken for surgery. Out of these 78 difficult cases, 68 cases were able to predict as per difficulty in dissecting GB from GB fossa. This gives a positive predictive value of 91%, which is in agreement with earlier studies. Conversion rate in our study was 9.6% of total and 11.5% of difficult cases. Those cases that were predicted pre-operatively with ultrasound to be easy were never converted to open. Conclusion: Pre-operative USG can be used as a screening method for laparoscopic cholecystectomy as this is a valuable predictor of difficulty in laparoscopic cholecystectomy in most of the cases. It will help the surgeon to make an idea of potential difficulty that he/she can face during the intra-operative period. The most valuable assessment using the ultrasound is the gall bladder wall thickness, gall bladder contracted or not, common bile duct diameter, and stones impacted in the neck of GB.

A scoring system for laparoscopic cholecystectomy to pick up difficult cases

Background The conventional surgical treatment for cholelithiasis is laparoscopic cholecystectomy (LC), although some patients still require conversion to open cholecystectomy, primarily due to technical challenges. Risk factor prediction before surgery aids in determining intraoperative challenges. There are several rating systems that can be used to anticipate intraoperative challenges during LC. However, a trustworthy and consistent scoring and prediction system must be developed. Aim and objectives to reduce complications from LC and establish a score system to anticipate difficult LC before surgery. Patient and methods This observational cohort research, which involved 50 patients with calculous cholecystitis, was conducted at the General Surgery Department of the Assiut University Hospitals. One day before to surgery, all patients undergoing elective LC underwent scoring procedures. The intraoperative activities were all documented. Every patient got the usual postoperative treatment and monitoring. Result The preoperative score and LC results were significantly correlated. Conclusion The improvement of patient counselling, surgical planning, and postoperative expectations is made possible by identifying preoperative risk factors that indicate difficult LC. These variables also assist the surgeon in LC difficulty prediction and in maintaining a lower threshold for conversion under tough intraoperative situations.

Cystic Duct Dissection Time as a Predictor of Difficult Laparoscopic Cholecystectomy

Background: The Tokyo 2018 guidelines call for the study of quantitative predictors of surgical difficulty in laparoscopic cholecystectomy for complete cholecystectomy in a safe context. Objective: To evaluate the cystic duct (CD) dissection time as a predictor of surgical difficulty. Materials and methods: This prospective study included 193 patients who underwent laparoscopic cholecystectomy in 2022 and were grouped according to the indication for cholecystectomy: Urgent, Delayed, and Elective. Multiple linear regression and multinomial logistic regression analyses were used to identify the preoperative and operative predictive variables of surgical difficulty. The predictive value of the time spent dissecting the CD was estimated using a ROC curve. Results: The CD dissection time of 13 min had 100% sensitivity and 99% specificity, PPV 100%, NPV 1%, OR 3.3 to predict the use of bailout techniques. Conclusions: The time required to dissect the cystic duct, with or without success, is a practical predictor of the subsequent use of bailout procedures and, consequently, predicts the "Risk/Difficult Cholecystectomy". Keywords: Difficult laparoscopic cholecystectomy, predictors of difficult cholecystectomy, bailout procedures, cystic dissection time, risk of cholecystectomy.

Utility of the Parkland Grading Scale to determine intraoperative challenges during laparoscopic cholecystectomy: a validation study on 206 patients at an academic medical center in Nepal

BackgroundMost of the scoring systems to predict difficult laparoscopic cholecystectomy are based on pre-operative clinical and radiological findings. Recently the Parkland Grading Scale system was introduced as a simple intra-operative grading scale. This study aims to utilize the Parkland Grading Scale system to assess the intraoperative challenges during laparoscopic cholecystectomy.MethodThis was a prospective, cross-sectional study done at Chitwan Medical College and Teaching Hospital, Chitwan, Nepal. All the patients underwent laparoscopic cholecystectomy from April 2020 to March 2021. Based on the initial intra-operative finding, Parkland Grading Scale was noted and at the end of the surgery, the level of difficulty was given by the operating surgeon. All the pre-operative, intra-operative, and post-operative findings were compared with the scale.ResultsOut of 206 patients, there were 176 (85.4%) females, and 30 (14.6%) males. The median age was 41 years (Range 19–75). The median body mass index was 23.67 kg/m2. There were 35(17%) patients with a history of previous surgery. The rate of conversion to open surgery was 5.8%. According to Parkland Grading Scale, 67(32.5%), 75(36.4%), 42(20.4%), 15(7.3%), and 7(3.4%) were graded as grade 1, 2, 3, 4, and 5 respectively. There was a difference in the Parkland grading scale in patients with a history of acute cholecystitis, gallbladder wall thickness, pericholecystic collection, stone size, and body mass index (p < 0.05). The total operative time, level of difficulty in surgery, rate of help needed from colleagues or replacement as the main surgeon, bile spillage, drain placement, gallbladder decompression, and conversion rate all increased with an increase in scale (p < 0.05). There was a significant increase in the development of post-operative fever, and post-operative hospital stay as the scale increased (p < 0.05). The Tukey-Kramer test for all pair-wise comparisons revealed that each grade was significantly different from each other (p < 0.05) on the difficulty of surgery except for grade 4 from 5.ConclusionParkland Grading Scale system is a reliable intra-operative grading system to assess the difficulty in laparoscopic cholecystectomy and helps the surgeon to change the strategy of surgery. An increase in scale is associated with an increased difficulty level of the surgery.

Validation of a Pre-Existing Scoring System for Preoperative Prediction of Difficulty in Laparoscopic Cholecystectomy

Background: One of the most commonly performed surgeries globally is Laparoscopic Cholecystectomy (LC) which is the gold standard surgical procedure for removal of gallbladder. It provides numerous benefits over open cholecystectomy but has also shown higher complication rates. Therefore, a system devised for pre operative assessment of intra operative difficulty level of Laparoscopic Cholecystectomy should be adopted to help with preparedness for complications and ensure an efficient course of surgery. Objective: The aim of this study was to validate a scoring system made by Randhawa Et al to assess intra operative difficulty level of Laparoscopic Cholecystectomy preoperatively. Study Design: This is a non randomized prospective observational study Methodology: This study was conducted in the department of general surgery unit 2 at Dow University Hospital, Karachi, Pakistan on 202 patients. Age, gender, BMI, history of previous hospitalization, examination finding of palpable gallbladder, previous abdominal surgery scars and sonographic findings including wall thickness of gallbladder, pericholecystic collection and impacted stone were considered to score a patient preoperatively. Results: Male gender and presence of pericholecystic fluid collection were found to be statistically significant in predicting intraoperative difficulty in patients undergoing laparoscopic cholecystectomy. Practical implications: Around 7 to 35% of laparoscopic cholecystectomy ends up getting converted into open cholecystectomy. This could be due to various reasons one of which is due to lack of preparedness for intraoperative difficulty in performing the surgery. For this reason, a scoring system that accurately predicts difficulty of surgery could help reducing this rate. Keeping this benefit in mind, a preformed scoring system was tested for its validity in assessing the intraoperative difficulty level of LC preoperatively. Keywords: Laparoscopic cholecystectomy, Scoring system, complications

Indocyanine green fluorescent cholangiography improves the clinical effects of difficult laparoscopic cholecystectomy.

Near-infrared fluorescent cholangiography (NIRFC) with indocyanine green (ICG) as the developer yields clear visualization of the extrahepatic bile ducts and is effective in identifying key structures. Here, we analyzed and compared the surgical outcomes of fluorescent and conventional laparoscopy in cholecystectomy of various difficulties and then assessed the value of NIRFC. This retrospective study collected clinical data from partial patients who underwent laparoscopic cholecystectomy (LC) at the Department of Hepatobiliary and Pancreatic Surgery, Zhongnan Hospital of Wuhan University between 2020 and 2021. The study subjects were classified into ICG-assisted and white-light laparoscopy. Two cohorts with homogeneous baseline status were selected based on 1:1 ratio propensity score matching (PSM). Multivariate logistic regression analysis was performed to predict independent risk factors for LC difficulty. Thereafter, the matched cases were classified into difficult and easy subgroups by combining difficulty score and gallbladder disease type, and then the surgical outcomes of the two groups were compared. This study included a total of 624 patients. The patients were classified into the ICG group (n = 218) and the non-ICG group (n = 218) after a 1:1 ratio PSM. Our data showed significant differences between the groups in operative time (P = 0.020), blood loss (P = 0.016), length of stay (P = 0.036), and adverse reaction (P = 0.023). Stratified analysis demonstrated that ICG did not significantly improve the surgical outcomes in simple cases (n = 208). On the other hand, in difficult cases (n = 228), NIRFC shortened operative time (P = 0.003) and length of stay (P = 0.015), reduced blood loss (P = 0.028) and drain placement rate (P = 0.015), and had fewer adverse reactions (P = 0.023). The data showed that five cases were converted to laparotomy while two cases had minor bile leaks in the non-ICG group. There was no bile duct injury (BDI) in all the cases. Furthermore, high BMI, history of urgent admission and abdominal surgery, palpable gallbladder, thickened wall, and pericholecystic collection were risk factors for surgical difficulty. ICG-assisted NIRFC provides real-time biliary visualization. In complicated conditions such as acute severe inflammation, dense adhesions, and biliary variants, the navigating ability of fluorescence can enhance the operation progress, reduce the possibility of conversion or serious complications, and improve the efficiency and safety of difficult LC.

Predicting difficulty in laparoscopic cholecystectomy preoperatively using modified Randhawa scoring system

Background: Laparoscopic cholecystectomy is a low-risk, minimally invasive operation and currently the standard for treatment of gallstone and gallbladder disease. Preoperative assessment of difficulty is required to prevent problems, ensure readiness, and ensure an effective course of surgery. Methods: In our work, we attempted to use a modified grading system developed by Randhawa et al. to preoperatively predict a difficult laparoscopic cholecystectomy. Age, gender, illness duration, history of prior GB disease, BMI, abdominal scar location (infra or supraumbilical), palpable gallbladder, and sonographic findings (gall bladder wall thickness, pericholecystic collection, and impacted stone) were assessed in patients who had been diagnosed with GB stones and required LC. Depending on the individual surgeon's assessment, a procedure is rated as easy, difficult, or very difficult. Results: On comparison of the test group difficulty level predicted with the gold standard of difficulty level intra op the test group has a sensitivity of 51.9 % and specificity of 100%. The test has a positive predictive value of 100% and Negative predictive value of 91.5%. The test and the gold standard agree on 154 out of 167 having a diagnostic accuracy of 92.21%. The Kappa value of 0.644 indicates very good agreement with a p value of &lt;0.001. Area under the curve indicates 96.1% of the difficulty is predicted by the Total score and significant with p value of &lt;0.001 Conclusions: The current modified Randhawa and Pujahari scoring method is useful and appropriate for forecasting operative outcome in laparoscopic cholecystectomy.

Prospective study of intraoperative and post-operative complications during laparoscopic cholecystectomy among patients presenting with acute calculous cholecystitis

Background: Acute cholecystitis was initially thought to be a contraindication for laparoscopic cholecystectomy. Now, as the experience is increasing, laparoscopic surgeons are gradually undertaking laparoscopic cholecystectomy as the preferred procedure even in an acute setting. Early surgery in acute presentation has better surgical outcome with lesser and cheaper hospital stay and predictive of better quality of life as compared to delayed treatment. Aims and Objectives: The objectives of this study were to study the perioperative complications during early laparoscopic cholecystectomy. Materials and Methods: One hundred and five patients with acute calculus cholecystitis visiting Fortis Escorts Hospital, Faridabad from June 2017 to November 2018 were studied. All patients underwent laparoscopic cholecystectomy and subsequently compared for the following intraoperative parameters: Presence of adhesions, calot’s anatomy, need for decompression of gallbladder, difficulty in dissecting the gallbladder from liver bed, retrieval of gallbladder, time taken to complete surgery, need of placement of drain, and need for conversion to open cholecystectomy. Complications studied were massive bleed, bile spillage during dissection, stone spillage, duodenal injury, and common bile duct [CBD] injury. Results: Decompression of the acute inflamed gallbladder facilitates laparoscopic cholecystectomy in acute cholecystitis with low conversion rate of 2.86%. Bleeding, CBD injury and duodenal injury are uncommon complications but major factors for conversion. Conclusion: Most common reasons for difficulty in laparoscopic cholecystectomy for acute cholecystitis were found to be adhesions in Calot’s triangle and adhesion of gallbladder with surrounding structures (duodenum/transverse colon).

Evaluation of Preoperative Scoring System for Predicting Difficult Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy (LC) is established as the gold standard for benign gallbladder disease. This study was done for the evaluation of preoperative scoring system given by Randhawa and Pujahari considering various preoperative parameters to predict difficulty in LC. Preoperative prediction of difficult LC using a scoring system considering various preoperative factors in elective/interval LC to predict difficult gallbladder. A prospective study of 120 patients admitted for LC from January 2020 to June 2021 was analyzed. All the patients were evaluated on the basis of Randhawa and Pujahari scoring system with the following variables: age >50 years, male sex, body mass index 25.1-27.5 and >27.5 kg/m2, previous abdominal surgery, prior hospitalization for gallstone disease, palpable gallbladder, gallbladder wall thickening, impacted stone, and pericholecystic collection. Each variable had given a score. Based on these findings, the surgical procedure was defined as easy, difficult, and very difficult. One hundred and twenty cases satisfying the inclusion criteria were studied comparing different variables and assigned preoperative scoring. A score >5 was considered significant and compared with intraoperative findings. Out of 53 patients having preoperative scores >5, 40 were difficult gallbladders and 13 were easy to operate. Prediction came true in 93.0% of difficult cases and 83.1% of easy cases. From this study, we can conclude that the preoperative scoring system is statistically reliable to predict difficulty in LC in the majority of the cases (area under receiver operator characteristics = 0.935).

Serum cholecystokinin levels can be a predictive factor for difficult cholecystectomy: Decreased cholecystokinin receptor levels.

Laparoscopic cholecystectomy (LC) is being performed frequently in general surgery practice. Estimation of difficult cholecystectomy is very important to take precautions against complications. Cholecystokinin (CCK) is an important enzyme for gall-bladder motility. CCK receptor is the target for CCK. Fibrosis and emptying problems of gallbladder are related with difficult cholecys-tectomies. We aimed to evaluate the association between plasma CCK and difficult cholecystectomy and try to explain the mechanism. Prospective cross-sectional study was conducted on a group of patients with cholelithiasis Patients who underwent elective cholecystectomy were classified into easy, difficult and very difficult preoperatively using LC difficulty scores. Pre-operative gallbladder empting ratios were measured by ultrasonography. Serum C-reactive protein, and postprandial serum CCK and pancreas polypeptide levels were measured before the operation. Operation data including operation times, adhesion scores, and complications were collected. Tissue CCK receptor levels and tissue fibrosis scores were obtained. Easy, difficult, and very difficult LC (DLC) groups were consisted of 34, 28, and 8 patients, respectively. Gallbladder emp-tying was 60% in easy LC group, but 15% in very DLC group. Plasma CCK levels in easy group (37.4 pg/ml) were significantly lower than plasma CCK levels of difficult (58.6 pg/ml), and very difficult groups (66.23 pg/ml). Tissue CCK receptor levels of easy, difficult, and very difficult were 372.4, 178.3, and 144.1 ng/100 mg, respectively. Adhesion scores and fibrosis scores of very difficult group were significantly higher than other groups. Operation times were significantly longer in very difficult group. There were two conversions to open in very DLC group (25%). CCK is a reliable parameter for determining the difficulty of LC. Decreased CCK receptor levels with fibrosis of gallbladder are the probably responsible mechanism.

OGBN P17 Preoperative scoring system in predicting difficulty in laparoscopic cholecystectomy

Abstract Background For a long time now, laparoscopic cholecystectomy (LC) has been the gold standard treatment for gallstone disease. Having said that, approximately 2–15% of attempted LCs have to be converted to an open procedure due to various difficulties faced while performing the procedure. This study has been structured and planned taking into account the various difficult situations a laparoscopic surgeon faces during laparoscopic cholecystectomy and assigns an objective outlook to the difficulty in the form of a difficulty score. The main objective of the study is to evaluate a scoring system in predicting difficulty in laparoscopic cholecystectomy. Methods Patients with symptomatic gallstone disease that were admitted in SU-1 of Holy family hospital during the above period were included in the study. For collection of data, a pre-tested questionnaire was used after taking informed oral consent. On admission, one day before the surgery, preoperative points were allotted on basis of patient's history, examination, hematological (CBC), biochemical (LFTs) and ultrasound results. Preoperative scores up to 5 was summed up as easy, scores 6–10 as difficult, 11–16 as very difficult. Calculated sample size was 229. SPSS version 22 and WHO Anthro calculator version 3.2.2 were used for data entry and analysis Results Among 230 patients that were included in the study, 188 were female and 42 were male. Various risk factors were found to have significant positive correlation with intraoperative difficulty during cholecystectomy. These are: Previous episodes of cholecystitis and pancreatitis (p=0.00), ERCP (p=0.00), tenderness in right hypochondrium (p=0.002), hepatitis serology (p=0.02), and Total Leukocyte Count (p=0.006). Whereas the following factors had insignificant relation with intraoperative difficult cholecystectomy: ALT and ALP (p&amp;gt;0.05, p=0.06 and 0.26 respectively) and hepatitis serology (p=0.406). A significant correlation was found between preoperative and intraoperative scores of the patients (p=0.003) indicating that preoperative assessment of various risk factors can predict the level of difficulty of cholecystectomy and its conversion to open cholecystectomy. Conclusions We may conclude that the scoring system evaluated in our study is a sturdy, reliable and useful benchmark to predict difficult cases. Preoperative prediction of the risk factors of conversion or difficulty of operation is an important point for operative planning and the high-risk patients may be informed accordingly.

WE8.1 Index admission cholecystectomy with or without single session bile duct exploration for emergency gall stone complications neutralised the adverse effects of COVID

AimsThe COVID-19 pandemic impacted surgical practice globally. We aim to study the effects this had on the presentations, practice and results of biliary surgery on a unit adopting index admission laparoscopic cholecystectomy (LC) and single session management of bile duct stones for emergency presentations.MethodsProspectively collected data of biliary surgery over a period of 12 months pre-COVID (PRE) and 12 months post-COVID (POST) was analysed. The presentation, type of admission, type of operating list and operative and postoperative data were compared.Results257 LCs were done PRE and 270 POST. All emergency presentations increased; acute cholecystitis 8.5% to 25.9%, acute pancreatitis 6.2% to 11.8% and jaundice 22.5% to 27.7%. Elective LC decreased from 53% to 20%. With an increase in patients with previous admissions (13.6% PRE vs 20.7% POST), 87% of PRE vs 80% POST had index admission LC, utilising 192 emergency theatre sessions and 29 CEPOD lists. In spite of increased LC difficulty grades (grades 4 and 5 from 20.2% to 30.5%), bile duct explorations (34%), operating time and median total hospital stay the morbidity, mortality and median presentation to resolution intervals were not affected.ConclusionsCovid-19 caused an increase in all acute biliary presentations requiring emergency admissions, almost certainly the result of a significant decline in elective LC. However, similar numbers of LC PRE and POST were maintained due to a policy of index admission surgery and bile duct exploration, utilising emergency theatre scheduling, optimised clinical outcomes in spite of some logistical parameters being affected.

Preoperative scoring system in predicting difficulty in laparoscopic cholecystectomy.

Objective: To evaluate a scoring system in predicting difficulty in laparoscopic cholecystectomy. Study Design: Non-Randomized Prospective study. Setting: Surgical Unit-1 of Holy Family Hospital, Rawalpindi. Period: January 2018 to September 2018. Material &amp; Methods: Patients with symptomatic gallstone disease that were admitted in SU-1 of Holy family hospital during the above period were included in the study. For collection of data, a pre-tested questionnaire was used after taking informed oral consent. On admission, one day before the surgery, preoperative points were allotted on basis of patient’s history, examination, hematological (CBC), biochemical (LFTs) and ultrasound results. Preoperative scores up to 5 was summed up as easy, scores 6 – 10 as difficult, 11 – 16 as very difficult. Calculated sample size was 229. SPSS version 22 and WHO Anthro calculator version 3.2.2 were used for data entry and analysis. Results: Among 230 patients that were included in the study, 188 were female and 42 were male. Various risk factors were found to have significant positive correlation with intraoperative difficulty during cholecystectomy. These are: Previous episodes of cholecystitis and pancreatitis (p=0.00), ERCP (p=0.00), tenderness in right hypochondrium (p=0.002), hepatitis serology (p=0.02), and Total Leukocyte Count (p=0.006). Whereas the following factors had insignificant relation with intraoperative difficult cholecystectomy: ALT and ALP (p&gt;0.05, p=0.06 and 0.26 respectively) and hepatits serology (p=0.406). A significant correlation was found between preoperative and intraoperative scores of the patients (p=0.003) indicating that preoperative assessment of various risk factors can predict the level of difficulty of cholecystectomy and its conversion to open cholecystectomy. Conclusion: We may conclude that the scoring system evaluated in our study is a sturdy, reliable and useful benchmark to predict difficult cases. Preoperative prediction of the risk factors of conversion or difficulty of operation is an important point for operative planning and the high-risk patients may be informed accordingly.

VALIDATION OF G10 CLASSIFICATION IN LAPAROSCOPIC CHOLECYSTECTOMY FOR THE PREDICTION OF OPERATIVE DIFFICULTIES: AN OBSERVATIONAL STUDY

Introduction: Laparoscopic cholecystectomy which is the gold standard of management of gall bladder pathologies has variability in terms of conversion to open procedure and operative difficulties according to the intraoperative findings.The G10 scoring system is used to predict the diificulty and outcome of surgery. Aims And Objectives: The study aimed at intraoperative assessment of gall bladder and its anatomy and surgical difficulty in laparoscopic cholecystectomy. Objective is to correlate the following factors :conversion to open procedure, surgical complication, operating time, hospital stay and readmission. Materials And Methods: All patients undergoing Laparoscopic cholecystectomy in College of Medicine and JNM Hospital, six months from the approval of Institutional Ethical Committee were used as samples. Result: 13% of difficult and 75% of extremely difficult cases were converted to open.In difficult level, 4.3% had bile duct injury, pericholecystic abcess formation and readmission whereas in extreme difficult level, 25% had bile duct injury, abcess formation and readmission. Conclusion: The more the G10 score, the more the difficulty level and there is more conversions and complications. Association of conversion,readmission and complications with degree of difficulty is statistically significant i.e. G10 classification remains a valid indicator for operative difficulties.

Operative Difficulty, Morbidity and Mortality Are Unrelated to Obesity in Elective or Emergency Laparoscopic Cholecystectomy and Bile Duct Exploration

ObjectivesThe challenges posed by laparoscopic cholecystectomy (LC) in obese patients and the methods of overcoming them have been addressed by many studies. However, no objective tool of reporting operative difficulty was used to adjust the outcomes and compare studies. The aim of this study was to establish whether obesity adds to the difficulty of LC and laparoscopic common bile duct exploration (LCBDE) and affects their outcomes on a specialist biliary unit with a high emergency workload. MethodsA prospectively maintained database of 4699 LCs and LCBDEs performed over 19 years was analysed. Data of patients with body mass index (BMI)≥35, defined as grossly obese, was extracted and compared to a control group. ResultsA total of 683 patients (14.5%) had a mean BMI of 39.9 (35–63), of which 63.4% met the definition of morbidly obese. They had significantly more females and significantly higher ASA II classifications. They had equal proportions of emergency admissions, similar incidence of operative difficulty grades 4 or 5 and no open conversions and were less likely to undergo LCBDE than non-obese patients. There were no significant differences in median operative times, morbidity, readmission or mortality rates. ConclusionsThis study, the first to classify gall stone surgery in obese patients according to operative difficulty grading, showed no difference in complexity when compared to the non-obese. Refining access and closure techniques is key to avoiding difficulties. Index admission surgery for biliary emergencies prevents multiple admissions with potential complications and should not be denied due to obesity.