History Of Acute Cholecystitis Research Articles

Pre-Operative Evaluation of Risk Factors for Difficult Laparoscopic Cholecystectomy

Cholelithiasis or the gallstone disease is the most common biliary pathology. 10-15% population of western world is estimated to be affected by gallstone disease, of which majority remains asymptomatic (>80%) and 1-2 % of these asymptomatic patients will develop symptoms needing surgery per year. In this prospective study, 77 patients years undergoing elective Laparoscopic Cholecystectomy (LC) and meeting all inclusion criteria in Department of General Surgery, Nepal Medical College and Teaching Hospital over period of 1 year. History, detailed clinical examination and laboratory investigations were performed as per the working proforma. Operative time and conversion to open cholecystectomy were recorded. The association between clinical, laboratory and sonographic factors with difficult laparoscopy were obtained. Data analysis was done using SPSS-17 version. Out of 77 patients, 63 were females. Body mass index (BMI) above 30 representing obese population were 33.2% with p value 0.0004. Also, 41.5% patients had history of acute cholecystitis while 12.9% patients had previous history of abdominal surgery and 70.1% patients had history of recurrent abdominal pain. Total of 19.4% patients had increased leucocyte count. On ultrasonography thickened GB wall of >3 mm was seen in 42.8%, distended GB was seen in 41.5%, stone size of >1 cm was seen in 70.1% patients and multiple stones were seen in 84.4%. Similarly, duration of surgery was >90 mins in 31.1% and 7.04% patients underwent conversion to open cholecystectomy both of which were considered difficult laparoscopy. Our study reveled that clinical factors like age, BMI, history of acute cholecystitis, previous history of recurrent abdominal pain and past history of abdominal surgery had significant association in prediction of difficult LC.

A Comparative Study of Laparoscopic Versus Robotic Cholecystectomies Based on the Parkland Grading Scale.

Background Cholecystectomy, the surgical removal of the gallbladder, is a common procedure performed to treat conditions like gallstone disease and cholecystitis. Among the various techniques available, laparoscopic cholecystectomy (LC) and robotic cholecystectomy (RC) are minimally invasive methods, while open cholecystectomy (OC) involves a more extensive incision and is reserved for cases where less invasive options are unsuitable. This study focuses on evaluating and comparing the safety and efficacy of LC and RC across different grades of cholecystitis, categorized by the Parkland Grading Scale. The goal is to determine whether RC provides significant benefits over LC, particularly in cases of higher-grade cholecystitis. Methodology This ambispective observational case-control study was conducted from January to June 2024 at Manipal Hospitals, Vijayawada, India. It included patients aged 18 or older with acute cholecystitis who underwent LC or OC. Exclusions were made for chronic cholecystitis, prior surgeries affecting the procedure, incomplete records, or severe complications. Data, including demographics, preoperative symptoms, intraoperative details, and postoperative outcomes, were extracted from electronic medical records. Laparoscopic procedures used standard techniques, while robotic procedures employed the da Vinci surgical system. Outcomes measured included operative time, complications, conversion rates, length of stay, and readmission rates. Results There was no significant difference in pre-operative parameters like age, white blood cell (WBC) count, total bilirubin, alanine transaminase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), or history of previous surgery according to the Parkland Grading Scale. However, differences were noted in the Parkland Grading Scale regarding the thickness of the gallbladder wall, incidence of pericholecystic collection, and history of acute cholecystitis (p < 0.05). The most common complication was bleeding during the operation, which was more frequent in LC and was significant. Other complications, such as bile duct injury and vascular injury, were not observed in either procedure. Conclusion This study highlights that RC provides notable benefits compared to LC, especially for higher grades of cholecystitis, as per the Parkland Grading Scale. Although robotic procedures have longer operative times, they result in fewer intraoperative and postoperative complications, reduced conversion rates, and lower readmission rates. These advantages make RC a promising choice for treating complex cases of cholecystitis.

Can Incidental Cancer be Predicted Before Cholecystectomies for Benign Diseases?

Objective: Gallbladder cancer is a rare disease with a high mortality rate. The gold standard of treatment is based on early diagnosis and eradication of the disease with effective surgery. Almost 70% of cases are detected incidentally in the final pathology report of routine cholecystectomies. Our study aims to predict incidental gallbladder cancer in patients scheduled for surgery for benign reasons. Methods: Biological characteristics, medical history, family history of hepatobiliary disease, radiological imaging, and laboratory parameters were analyzed in 2852 patients operated on for benign reasons in the general surgery department over 63 months. Patients with incidental gallbladder cancer were compared with patients with cholecystitis. The effects of independent variables in predicting cancer between the two groups were analyzed. Results: Of 2852 patients who underwent cholecystectomy, 13 (0.45%) had incidental gallbladder cancer. The cancer incidence rate was 0.28% (2/700) in men and 0.51% (11/2139) in women. This difference was not statistically significant (p: 0.34). Among the biological characteristics, history of acute cholecystitis (p: 0.001), and laboratory findings, neutrophil-to-lymphocyte ratio (NLR) (p: 0.001) were the most striking variables. When variables with proven statistical value were tested by logistic regression analysis, NLR (p: 0.001), biliary polyps (p: 0.001), and gallstones (p: 0.038) were ranked as the most valuable cancer predictors, respectively. Conclusions: In older patients with a history of acute cholecystitis, especially if there are large stones, polyps, and wall thickening on imaging, the possibility of cancer should be considered considering the NLR value, and surgery should be performed under optimal conditions by informing the patient and relatives.

Safety of cholecystectomy performed by surgeons who prefer fundus first versus surgeons who prefer a standard laparoscopic approach

BackgroundAn alternative method to standard laparoscopic cholecystectomy (SLC) is the “fundus first” method (FFLC). Concerns have been raised that FFLC can lead to misinterpretation of important anatomical structures, thus causing complications of a more serious kind than SLC. Comparisons between the methods are complicated by the fact that FFLC is often used as a rescue procedure in complicated cases. To avoid confounding related to this we conducted a population-based study with comparisons on the surgeon level. MethodIn GallRiks, the Swedish registry for Gallbladder surgery, we stratified all cholecystectomies performed 2006–2020 in three groups: surgeries carried out by surgeons that uses FFLC in <20 % of the cases (N = 150,119), in 20–79 % of the cases (N = 10,212) and in 80 % or more of the cases (N = 3176). We compared the groups with logistic regression, adjusting for sex, age, surgical experience, year of surgery and history of acute cholecystitis. All surgical complications (bleeding, gallbladder perforation, visceral perforation, infection, and bile duct injury) were included as outcome. A separate analysis was done with regards to operation time. ResultsNo difference in incidence of all surgical complications or bile duct injury were seen between groups. The rates of bleeding (OR 0.34 [0.14–0.86]) and gallbladder perforation (OR 0.61 [0.45–0.82]) were significantly lower in the “fundus first > 80% group” and the operative time was shorter (OR 0.76 [0.69–0.83]). ConclusionIn this study including >160,000 cholecystectomies, both methods was found to be equally safe. Key messageDuring laparoscopic cholecystectomy, the standard method of dissection and fundus first dissection are equally safe surgical techniques. Surgeons need to learn both methods to be able to use the one most appropriate for each individual case.

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.

Risk Factors Associated with Conversion of Laparoscopic to Open Cholecystectomy

Abstract: Background: Gallstones disease is one of the major problem of gastro intestinal tract and surgical removal is usually advised. Surgery is usually laparoscopic but if the dissection is tedious, laparoscopic procedure can be converted into open procedure. Objective: This study aims to assess the reasons and risk factors for the conversion of laparoscopic cholecystectomy (LC) into open cholecystectomy (OC). Materials and Methods: A prospective assessment of medical records of patients who underwent laparoscopic cholecystectomy at ward-2, Jinnah Postgraduate Medical Centre from January 2019 to December 2021 was undertaken to identify indications of all laparoscopic cholecystectomies converted to open cholecystectomy and assess operative time and length of hospital stay of these patients. Results: A total of 984 elective cholecystectomies were performed in which 85.5% (n=841) were females and 14.5% (n=143) were males. Male to female ratio was 1:5.8 with conversion rate 0.40 % (n=04) and 4.36% (n=43) respectively. Laparoscopic cholecystectomy was done in 95.22% (n=937) cases while 4.78% (n=47) patients required conversion to open cholecystectomy with major pre-operative risk factors being acute cholecystitis (p&lt;0.001), history of acute cholecystitis (p=0.012), history of acute pancreatitis (p=0.007), history of previous open surgery (p&lt;0.001) and major per-operative risk factors being severe bleeding (p&lt;0.001), dense adhesions (p=0.755), distorted anatomy (p&lt;0.001), visceral damage (p&lt;0.001) and biliary injury(p&lt;0.001). Conclusion: We have identified some important risk factors for the conversion of surgical approach for acute cholecystitis. However, the open approach should be done by experienced surgeons when necessary. The overall impact of the study is to identify the patients who are the risk of conversion into open preoperatively so that proper arrangement and counseling should be done.

Development and validation of a nomogram model for predicting the risk of gallstone recurrence after gallbladder-preserving surgery

BackgroundThe high incidence of gallstone recurrence was a major concern for laparoscopic gallbladder-preserving surgery. This study aimed to investigate the risk factors for gallstone recurrence after gallbladder-preserving surgery and to establish an individualized nomogram model to predict the risk of gallstone recurrence. MethodsThe clinicopathological and follow-up data of 183 patients who were initially diagnosed with gallstones and treated with gallbladder-preserving surgery at our hospital from January 2012 to January 2019 were retrospectively collected. The independent predictive factors for gallstone recurrence following gallbladder-preserving surgery were identified by multivariate logistic regression analysis. A nomogram model for the prediction of gallstone recurrence was constructed based on the selected variables. The C-index, receiver operating characteristic (ROC) curve and calibration curve were used to evaluate the predictive power of the nomogram model for gallstone recurrence. ResultsDuring the follow-up period, a total of 65 patients experienced gallstone recurrence, and the recurrence rate was 35.5%. Multivariate logistic regression analysis revealed that the course of gallstones > 2 years [odds ratio (OR) = 2.567, 95% confidence interval (CI): 1.270-5.187, P = 0.009], symptomatic gallstones (OR = 2.589, 95% CI: 1.059-6.329, P = 0.037), multiple gallstones (OR = 2.436, 95% CI: 1.133-5.237, P = 0.023), history of acute cholecystitis (OR = 2.778, 95% CI: 1.178-6.549, P = 0.020) and a greasy diet (OR = 2.319, 95% CI: 1.186-4.535, P = 0.014) were independent risk factors for gallstone recurrence after gallbladder-preserving surgery. A nomogram model for predicting the recurrence of gallstones was established based on the above five variables. The results showed that the C-index of the nomogram model was 0.692, suggesting it was valuable to predict gallstone recurrence. Moreover, the calibration curve showed good consistency between the predicted probability and actual probability. ConclusionsThe nomogram model for the prediction of gallstone recurrence might help clinicians develop a proper treatment strategy for patients with gallstones. Gallbladder-preserving surgery should be cautiously considered for patients with high recurrence risks.

Choque séptico de origen biliar en la Unidad de Cuidados Intensivos

Se presenta un caso de choque séptico de origen biliar en un paciente de sexo masculino de 76 años, con antecedente de colecistitis aguda y su correspondiente resolución quirúrgica. Ingresa a la Unidad de Cuidados Intensivos (UCI) del Hospital General San Vicente de Paúl, de Ibarra, con apoyo de dispositivo de ventilación con presión positiva, RASS -5 con efectos de sedoanalgesia, presencia de acceso venoso central yugular derecho, abdomen con presencia de bolsa de Bogotá y sonda vesical permeable. Luego de 16 días en UCI, a pesar de tratamiento médico, evoluciona tórpidamente y fallece. Cabe recalcar que no se efectuaron exámenes post mortem. En términos generales, la sepsis biliar constituye la disfunción multiorgánica originada en el contexto de infección de la vía biliar principal (VBP) o vía biliar accesoria (VBA). En este caso se revisa la cronología de un paciente con diagnóstico de choque séptico de origen biliar, la clínica y el manejo. En efecto, establecer el diagnóstico tardío de colecistitis aguda determina consecuencias graves como la perforación vesicular, sepsis grave o choque séptico de origen biliar con el mal pronóstico consecuente. El tratamiento es quirúrgico y consiste en colecistectomía, lavado quirúrgico y drenaje, e incluso en la reparación de las complicaciones que se presenten. Gran parte de la mejora en la mortalidad asociada con el shock séptico está relacionada con el reconocimiento precoz combinado con la reanimación con líquidos intravenosos y la administración de antibióticos.

Initial experience of intraoperative fluorescent cholangiography during laparoscopic cholecystectomy: A retrospective study

BackgroundFluorescent cholangiography (FC) during laparoscopic cholecystectomy (LC) is a novel method to facilitate real-time visualization of extrahepatic biliary structures that avoiding risk of bile duct injury. Aims of this study are to investigate the feasibility and the safety of FC during LC. MethodWe evaluated the outcomes of FC during elective LC at our hospital from August 2017 to April 2018. Fifty-five patients who underwent FC during elective LC were enrolled in this study. Demographic and peri-operative data were recorded and analyzed. The primary endpoints were visualization rate of FC during LC. The secondary endpoint was the optimal conditions and technical details for FC included to detect any potential adverse event. ResultsThe visualization rate after FC of the cystic duct, common hepatic duct and common bile duct were increased significantly compared to before FC. The identification rate of the cystic duct and common bile duct were not associated with BMI and history of acute cholecystitis. ConclusionsFC enabled real-time visualization of extrahepatic biliary structures during LC. FC appears to be a safe and efficient approach for elective LC.

A prospective observational study to study and correlate the clinical and microbiological profile of bile cultures in patients with symptomatic cholelithiasis

Background: Biliary infection has been reported in a significant proportion of patients developing gallstones. Many studies have found biliary microflora in 20% to 46% patients with a post-operative infection rate of 7% to 20% in those who undergo cholecystectomy for symptomatic gallstone disease. Various antibiotics are also used empirically as prophylaxis against post-operative infection. The study was conducted in order to determine the bacteriology and to test its sensitivity to commonly used antibiotics of aspirated bile samples taken during laparoscopic cholecystectomy, and to correlate it with the clinical profile recorded in patients with symptomatic cholelithiasis.Methods: A total of 266 patients who underwent laparoscopic cholecystectomy were included in the study over a two year period. Intra operatively, bile was aspirated from gall bladder and sent for culture and antibiotic sensitivity testing.Results: 14.66% (39 out of 266) patients had positive growth with Escherichia coli most commonly isolated in 9.77% (26/266) patients, followed by the Klebsiella species in 4.89% (13 out of 266) patients. All the cultures were sensitive to amikacin and meropenem, 97.44% to imipenem, and only 43.39% were sensitive to ampicillin. A statistically significant correlation was observed between a positive bile culture with the duration of symptoms (p=0.01874) and gall bladder thickness (p&lt;0.0001). No correlation was seen between bile culture and history of acute cholecystitis, number or size of calculi.Conclusions: The results of this study can help develop local guidelines and recommendations based on Indian data to ensure the rational use of prophylactic antibiotics in patients with symptomatic cholelithiasis.

Surgical treatment of an intraductal papillary mucinous neoplasm of the biliary tract diagnosed by SpyGlass�

We present the case of a 76-year-old male with a history of acute cholecystitis who underwent a scheduled laparoscopic cholecystectomy. Chronic cholecystitis with a thickened cystic duct was observed intraoperatively. The anatomic pathology report found high-grade dysplasia that affected the distal edge of the cystic duct. In view of these findings, an endoscopic retrograde cholangiopancreatography (ERCP) was performed with SpyGlass® and an excrescent lesion suggestive of malignancy adjacent to the cystic-common bile duct junction was observed. A resection of the extrahepatic bile duct was performed with lymphadenectomy of the hepatic hilum and hepaticojejunostomy in a subsequent procedure. The definitive pathology report confirmed pancreaticobiliary intraductal papillary mucinous neoplasia with high-grade dysplasia and free margins.

Difficult Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is as much easy procedure as difficult one. Surgeon should consider every case as his first one. Intraoperative complications are common while transformation to open surgery should be always in consideration. Transformation to open cholecystectomy isn&amp;#39;t a sign of lack of experience, rather it is a proof of surgeon cleverness and an evidence of professional competence as it could keep our patient away from life-threatening complications in difficult situations.&#x0D; &#x0D; Predictive factors for difficulty vary from male patient, repeated acute attacks, history of obstructive jaundice, presence of abnormal anatomical or pathological findings, and adhesions.&#x0D; &#x0D; The aim of this study was to assess some preoperative causes namely by history, clinical examination and, radiological data which can dependably anticipate the odds of troublesome laparoscopic Cholecystectomy or alteration to open Cholecystectomy .1005 patients experienced laparoscopic cholecystectomy 171 of them were difficult cases (10.05%). Transformation rate in our study is within the lower limits and accepted internationally. Dense fibrous adhesion and bleeding are the main causes of transformation. History of acute cholecystitis is separate hazard factor for transformation from laparoscopic to open procedure. Gender and age are also showing increasing rate of transformation.&#x0D; &#x0D; Results shown bile duct damages may evaded even with nearness of hazard factors as anatomical variations from the of biliary channels, intense cholecystitis, extreme endless fibrosis, affected stones inside Hartmann pocket, and short cystic pipe during laparoscopic cholecystectomy by careful watching and wise decision of transformation whenever surgeon feels risk of major complication in case of proceeding in laparoscopic technique.&#x0D; &#x0D; Mortality not encountered directly through the procedure or in short post-operative period but as sequel of complicated cases. Authors proposes that change of the laparoscopic cholecystectomy isn&amp;#39;t really a disappointment of the specialist, as usually explained, yet is a lifesaving method as delineated by the results of the study. The experience of the operating surgeon assumes an essential function on this subject.

Preoperative indicators of technically difficult laparoscopic cholecystectomy using clinical and ultrasonographic parameters

Background Laparoscopic cholecystectomy (LC) has rapidly become the operation of choice for routine gallbladder (GB) removal. The purpose of this study is to provide preoperative indicators of a technically difficult LC based on various preoperative clinical and ultrasonographic predictors. Patients and methods This study was conducted in the General Surgery Department, Ohud General Hospital, Al Madinah Al Munawarah, Saudi Arabia, for 280 patients with diagnosis of gallstones confirmed by abdominal ultrasonography and subjected to LC. The technical difficulty of the surgical procedure was assessed postoperatively (either easy, difficult, or very difficult) based on operative time (min), spillage of bile and/or stones, bile duct injury, and the need for conversion to open surgery. Results The present study found that old age; male sex; previous history of acute cholecystitis or acute pancreatitis; history of previous abdominal surgery; urgent surgery after 72 h of the onset of symptoms in acute cholecystitis; morbid obesity; ultrasonographic findings including increased of GB wall thickness, impacted stones, sonographic Murphy’s sign, and pericholecystic fluid collection; and palpable GB increase the technical difficulty of LC. Conversion to open cholecystectomy was seen in only one patient. Conclusion Clinical and radiological patient characteristics are good preoperative predictors for the technical difficulty of LC and can help the surgeon to anticipate the risk for intraoperative complications and the possible need for conversion to open cholecystectomy.

Study of risk factors for conversion during laparoscopic cholecystectomy in a tertiary care teaching hospital

Laparoscopic cholecystectomy has become the standard treatment for symptomatic gall bladder disease. However, there still a substantial proportion of patients in whom Laparoscopic cholecystectomy cannot be successfully performed, and for whom conversion to open surgery is required. This was a longitudinal study conducted in surgical unit of Sri Siddhartha Medical College. All the patients who had right hypochondriac pain and diagnosed with cholelithiasis on USG were included in the study. From the data collected, only factors available to surgeon preoperatively were considered for analysis. These factors included: age, gender, history of acute Cholecystitis, obesity and concomitant disease, In our study 90 patients were underwent laparoscopic cholecystectomy Out of 90 total patients included in the study 81 patients had underwent successful Laparoscopic cholecystectomy and 9 patients needed conversion to open cholecystectomy. The conversion rate is 10% which is consistent with the other studies. The most common reason for conversion was difficult to define anatomy in patients with inflamed, contracted gall bladder. Significant predictor factors for conversion were male gender, acute Cholecystitis, and obesity. In our study it is concluded that Male sex, Age >50yrs, obesity (BMI>35 kg/m2), and cholecystitis are considered risk factors for conversion of Laparoscopic cholecystectomy to Open cholecystectomy. These factors can predict difficulty to be encountered during surgery and help in making a decision for conversion thus shortening the duration of surgery and preventing unnecessary complications.

Small-incision cholecystectomy (through a cylinder retractor) under local anaesthesia and sedation: a prospective observational study of five hundred consecutive cases.

Transcylindrical cholecystectomy (TC) can be performed under local anaesthesia and sedation (LAS) in ambulatory surgery (AS). The aim of this study was to assess the feasibility and results of TC under LAS. TC under LAS was proposed to 583 consecutive patients with cholelithiasis in an AS unit. For the TC procedure, a cylindrical retractor with a transparent plunger was inserted into the hepatocystic triangle, and cholecystectomy was performed through the retractor with reusable open instruments. Pre-, intra-, and post-operative variables were prospectively registered, including complications, reasons for conversion to general anaesthesia (GA), non-programmed admissions, readmissions, pain assessments, and satisfaction with the procedure. Five hundred patients were eligible for LAS, with GA being required in 128 (25.6%) of them. AS was programmed for 447 patients. The rates of non-programmed admissions, readmissions, and conversion to laparotomy were 8.7% (39), 0.8% (4), and 2.6% (13), respectively. There was no main bile duct injury. At 24h, physical status was good or excellent in 80.4% of the patients. A history of acute cholecystitis, male sex, a body mass index (BMI) ≥ 39.5kg/m2, and non-suspected acute cholecystitis were found to be independent variables associated with conversion to GA. TC under LAS is a safe procedure in AS and is feasible in 74% of cholelithiasis patients. Male sex, BMI, gallbladder wall thickness, and a history of acute cholecystitis are factors that increase the probability of conversion to GA. This prospective study was approved by the ethics committee of Badajoz for patient protection for biomedical research and has been retrospectively registered under the research registry UIN: researchregistry3979.

Pre-operative factors for predicting a difficult laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is a very safe procedure yet there are instances where serious complications can be avoided and better managed if the surgeon is forewarned or prepared in advance for them. So, a need is felt to identify pre-operative parameters for anticipating a difficult cholecystectomy.Methods: This study was carried over a period of two years (2007- 2009). Patients having symptomatic cholelithiasis willing to undergo laparoscopic cholecystectomy were enrolled in the study. The following pre-operative parameters were evaluated in the study: age, sex, body mass index, history of previous abdominal surgery, history of acute cholecystitis, history of biliary colic, palpable lump in right hypochondrium, experience of the surgeon and abdominal ultrasonogram (following parameters were noted increased gallbladder wall thickness, number of stones, size of largest stone and its location).Results: Acute cholecystitis, palpable gall bladder, increased gallbladder wall thickness, biliary colic, gall stones &gt;2 cm in size, gall stone impacted at gallbladder neck and BMI &gt;30 kg/m2 had a significant p-value in a difficult laparoscopic cholecystectomy.Conclusions: Further research is needed to formulate a score based on the variables mentioned above to predict a difficult laparoscopic cholecystectomy and hence letting the surgeon be better prepared for any eventualities that he encounters whilst performing laparoscopic cholecystectomy.

Predictive factors for conversion from laparoscopic to open cholecystectomy: an institutional study

Background: Laparoscopic cholecystectomy has become the gold standard treatment for symptomatic gallstones. However, a conversion to open surgery may be required to complete the procedure safely. The aim of this study is to identify the predictive factors of conversion from laparoscopic to open cholecystectomy in elective setting.Methods: A retrospective review of all patients underwent laparoscopic cholecystectomy electively for symptomatic gallstones from January 2016 to December 2017 was performed. Data considered for analysis were: demographic data, preoperative laboratory values of liver function tests, gall bladder wall thickness on ultrasound, preoperative ERCP, indication for surgery, history of acute cholecystitis, presence of intraoperative adhesions and frozen Calot's triangle. Conversion to open cholecystectomy was chosen as the dependent variable for both, univariate and multivariate analysis.Results: 546 patients underwent laparoscopic cholecystectomy. 333 were females (60.9%) and 213 (39.1%) males, with a mean age of 44.6 years. The most common indication for surgery was symptomatic cholelithiasis. Conversion to open cholecystectomy occurred in 48 cases (8.8%) and the most common reason for conversion was inability to define the Calot’s triangle anatomy due to inflammation/adhesions. Univariate and multivariate analyses of various variables demonstrated that male gender, gall bladder wall thickness &gt;5 mm and presence of previous documented acute cholecystitis had statistically significant co-relation with higher rates of conversion (p&lt;0.001).Conclusions: Presence of acute cholecystitis, gall bladder wall thickness &gt;5mm on preoperative ultrasound and male gender were independent predictor factors for conversion from laparoscopic to open cholecystectomy. Such patients should be properly counselled about the increased risk for conversion and should be operated by surgeons experienced in laparoscopic procedures to reduce the rate of conversion and operative complications.

Predicting difficult laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy (LC) has become the gold standard treatment for gallstone disease. Though mostly safe occasionally it can be difficult due to various problems faced during surgical procedure. Anticipation of likely difficulty can help in avoiding complications.Methods: With the aim of identifying various predictors of difficulty and their correlation with likely difficulty this prospective study on 50 adults undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis was undertaken. Various clinical, radiological and biochemical predictors and frequency and type of intraoperative difficulty was recorded.Results: In present study adverse clinical factors only showed significant predictive value (p value - 0.005). Adverse radiological predictors although showing trend towards, did not achieve statistical significance (p value 0.065). In clinical predictors duration of symptoms &gt;1yr, History of acute cholecystitis and BMI &gt;30 showed statistically significant association. Age &gt;50yrs, Male gender, radiological predictors (Thickened gall bladder wall, small contracted gall bladder, Single large impacted stone) and deranged LFT did not show significant predictive value.Conclusions: Clinical predictors are most reliable factors. Use of good clinical judgement regarding possibility of and likely difficulty along with understanding of available resources is important in making decision in each case.

Per-operative conversion of laparoscopic cholecystectomy to open surgery: prospective study at JSS teaching hospital, Karnataka, India

Background: Laparoscopic cholecystectomy has become the standard treatment for symptomatic gall bladder disease. However, there still a substantial proportion of patients in whom Laparoscopic cholecystectomy cannot be successfully performed, and for whom conversion to open surgery is required. Methods: In this study, 800 laparoscopic cholecystectomy performed at JSS teaching hospital from September 2014 to September 2016, were prospectively analyzed. The patients studied included 800, 518 were females (65%) and 282 were males (35%) with a mean age of 44.8 years. From the data collected, only factors available to surgeon preoperatively were considered for analysis. These factors included: age, gender, history of acute cholecystitis, jaundice, previous abdominal surgery, obesity and concomitant disease, ultrasound preoperatively and amp; ERCP. Results: Of the 800 patients who were subjected to laparoscopic cholecystectomy, 23 patients (2.9%) required conversion to open surgery. The most common reason for conversion was dense adhesions, followed by suspicion of CBD injury and inability to define anatomy of calot’s triangle in patients with inflamed, contracted gall bladder (n = 42).Significant predictor factors for conversion were chronic calculous cholecystitis, previous upper abdomen surgeries and CBD injuries . Conclusions: Laparoscopic cholecystectomy has indeed become the gold standard for gall bladder diseases, however a conversion rate of up to 5% is internationally accepted. The conversion rate at our institute was 2.9%. This study shows the pre-operative parameters which enables a surgeon to anticipate need for conversion and hence be prepared.

Pre-operative Prediction of Difficult Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is one of the most common operation performed. Though LC have become safer and easier at times it can be difficult. Difficult cases can result in prolonged operative time, bleeding, bile spillage, conversion to open technique and bile duct injury resulting in unplanned prolonged hospital stay, increase in estimated cost to the patients and for the surgeon it leads to increased stress during operation and time pressure to complete the operative list. . Identification of difficult cases has potential advantages for surgeons, patients and their relatives. We aim to develop and validate a scoring system to predict difficult LC preoperatively. Prospective study. History, physical examination, abdominal ultrasound and biochemical parameters were included to develop a scoring system. Hundred patients undergoing LC were included and preoperative scores were calculated preoperatively to predict difficult LC which was compared with operative assessment. Sensitivity and specificity of the preoperative scoring for difficult case was 53.8 % and 89.2 % respectively with PPV of 63.64 % and NPV of 84.62%. Only three parameters (history of acute cholecystitis, gall bladder wall thickness and contracted gall bladder) were statistically significant to predict difficult LC individually. Area under ROC curve was 0.779 (95 % CI, 0.657-0.883). Preoperative scoring system can be used to predict difficult LC. Surgeons can plan operation based on predicted difficulty. Patients and relatives can be counselled preoperatively for the possibility of difficult operation, prolonged hospital stay and increased cost in predicted difficult case.