Predictors Of Difficult Laparoscopic Cholecystectomy Research Articles

Liver pucker sign: predictor of difficult laparoscopic cholecystectomy: a case series.

Pucker sign is the depression of the liver in the region of the gallbladder due to a high degree of chronic contractive inflammation of the gallbladder. It usually develops in patients who have a delayed cholecystectomy after acute cholecystitis due to a high degree of chronic contractive inflammation of the gallbladder and contraction of the cystic plate. It is an essential finding either preoperatively or intraoperatively as it can act as a stopping rule during cholecystectomy (act as a guide that cholecystectomy will be difficult). The authors here report three cases of pucker sign that were incidentally discovered during laparoscopy. Chronic cholecystitis is a prolonged, subacute condition caused by inflammation of the gallbladder, which mostly occurs in the setting of cholelithiasis. Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Hence, it would be beneficial to be aware of reliable signs that predict difficult Laparoscopic cholecystectomy. Pucker sign usually predicts increased operative difficulty as there is an operative danger of biliary or vascular injury. The pucker sign is a novel indicator of significant persistent inflammation and heightened difficulty during surgery. It might establish a halting rule that modifies the procedure's management and raises its level of safety.

Predicting Difficulty in Laparoscopic Cholecystectomies: An Evaluation of the Labbad-Vivas Score and Its Correlation With the Parkland Grading Scale.

Background Difficult laparoscopic cholecystectomy (DLC) denotes the surgical extraction of the gallbladder under circumstances where associated conditions within the same organ, adjacent structures, or patient-specific conditions impede a smooth, expeditious, and comfortable dissection. It is imperative to utilize tools that aid in anticipating this challenging surgical scenario, enabling the implementation of appropriate measures. Objective This study aimed to assess the effectiveness of the Labbad-Vivas score (LVS) in predicting DLC and its correlation with the Parkland Grading Scale (PGS). Methodology A prospective study was conducted, including patients diagnosed with gallstone disease undergoing LC (laparoscopic cholecystectomy) at the "Dr. Luis Razetti" University Hospital in Barcelona, Venezuela, between September and December 2023. Results Forty patients were studied, with 80% (n=32) being female and 95% (n=38) under the age of 65; surgeries were elective in 72.5% (n=29) of cases; 35% (n=14) had an LVS ≥16 (difficult cholecystectomy); and 62.5% (n=25) of patients presented Grades 1 and 2 on the PGS. Total cholecystectomy was performed in 95% (n=38) of the patients. The LVS showed a sensitivity of 80%, specificity of 92%, positive predictive value of 85.7%, and negative predictive value of 88.5% to predict DLC, with an area under the receiver operating characteristic curve of 0.897 (95% confidence interval (CI) = 0.792-1.003). A Pearson correlation coefficient of 0.805 (95% CI = 0.656 - 0.904) was obtained between both scores. Conclusion The use of the LVS score in the preoperative setting is feasible as a predictor of DLC, given its effectiveness and high correlation with the PGS.

Role of C-Reactive Protein as a Predictor of Difficult Laparoscopic Cholecystectomy.

Cholelithiasis is one of the most common diseases encountered in gastroenterology. Laparoscopic cholecystectomy can be labelled as difficult if the surgery continues for more than 60minutes or if the cystic artery is injured before ligation or clipping. Predicting difficult laparoscopic cholecystectomy can help the surgeon to be prepared for intraoperative challenges such as adhesions in triangle of Calot, injury to cystic artery or gall stone spillage; and improve patient counseling. In this cross-sectional study, we evaluated 269 patients with diagnosed cholelithiasis and planned for laparoscopic cholecystectomy in the general surgery department of Civil Hospital Karachi. After approval of the institution review board of the Civil Hospital, the data of all the patients was collected along with informed consent. The patients were selected via nonprobability, consecutive sampling. The prevalence of difficult LC during procedure was 14.5% (39/269). Contingency table showed the true positive, negative and false positive and negative observation and using these observation to compute accuracy. Sensitivity, specificity, PPV, NPV and accuracy of serum c-reactive protein (CRP) in predicting the difficult laparoscopic cholecystectomy in patients of cholelithiasis was 87.2%, 97%, 82.9%, 97.8% and 95.5% respectively. Effect modifiers like age, gender and BMI were controlled by stratification analysis and observed that diagnostic accuracy was above 90% in all stratified groups as presented in the following tables. 175 (65.06%) of 279 patients were females indicating female predominance. In general, 41 patients (15.05%) had CRP serum levels greater than 11mg/dL out of which 34 patients had to undergo difficult laparoscopic cholecystectomy (DLC), while 223 out of 228 patients with serum CRP levels of less than 11mg/dL did not face any difficulty during their cholecystectomy. Similar results have been acquired across all age groups and both genders. C Reactive Protein is a potent predictor of difficult laparoscopic cholecystectomy and its conversion preoperatively. Patients with preoperatively high C Reactive Protein CRP levels in serum have more chances of complication intraoperatively and increased chances of conversion from laparoscopic to open surgery. Preoperative C Reactive Protein (CRP) with values >11mg/dL was associated with the highest odds of presenting difficult laparoscopic cholecystectomy (DLC) in our study. This value possesses good sensitivity, specificity, PPV, and NPV for predicting DLC in our population.

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.

Clinical, laboratory, and radiological predictors of difficult laparoscopic cholecystectomy: A case control study

Clinical, laboratory, and radiological predictors of difficult laparoscopic cholecystectomy: A case control study

A Study of Preoperative Predictors of Difficult Laparoscopic Cholecystectomy

Introduction : Laparoscopic cholecystectomy is the most commonly performed surgery for various gallbladder disorders nowadays. Difficulty during laparoscopic cholecystectomy is being faced by many surgeons. If the difficulties are detected preoperatively, management can be planed accordingly by the surgeon. In this study, preoperative clinical and radiological evaluation of patient were studied to predict the difficulties during laparoscopic cholecystectomy. Materials and Methods: All patients who are undergoing laparoscopic cholecystectomy are evaluated by their Name, Age, Sex, BMI, clinically palpable gallbladder, ultrasound findings are correlated with the preoperative score for the prediction of difficulty during laparoscopic cholecystectomy in this study. Results: Upon analyzing of risk factors with pre operative risk score, there was a significant association with BMI, palpable gallbladder, GB wall thickness, impacted gall stones and peri cholecystic collection. Conclusion: This study combined the preoperative clinical and radiological parameters for better prediction of difficult Laparoscopic Cholecystectomy. It provides a base for further studies to validate in this aspect, and it also aids in formulating an efficient scoring system for prediction of difficult Laparoscopic Cholecystectomy and reducing the incidence of complications.

Pre-operative predictors of difficult laparoscopic cholecystectomy: a comparative study between two scoring systems

Background: Laparoscopic cholecystectomy is considered as the gold standard in treating symptomatic gall bladder disease. It has now become the most common operation performed by general surgeons. At times laparoscopy becomes difficult and may need conversion to open cholecystectomy. Many scoring systems are developed to predict the difficulty of laparoscopic cholecystectomy pre operatively. Our study aims to determine factors predicting difficult cholecystectomy and validate 2 scoring systems i.e., risk score for conversion from laparoscopic to open cholecystectomy (RSCLO) vs. new scoring system (NSS).Methods: Patients presenting to Kempegowda institute of medical sciences from January 2014 to August 2015 with symptoms of gall stone disease were screened for cholelithiasis.100 patients undergoing laparoscopic cholecystectomy were randomly selected. Every patient was given pre-operative score, after applying their symptoms to the scoring system and these scores were compared with the intraoperative findings and post-operative outcome. Thereby, calculating the sensitivity and specificity of the scoring systems.Results: On univariate and multivariate logistic regression-BMI>27.5 kg/m2 (p=0.010), Palpable gallbladder (p=0.022), previous hospitalization for acute cholecystitis (p=0.15), Sonology: wall thickness>4 mm (p=0.0015), presence of pericholecystic edema, were found statistically significant. RSCLO system was better in predicting easy cholecystectomy i.e., low risk for conversion, while NSS was better in predicting difficult, very difficult cholecystectomies {converted cases}, its sensitivity being 100%.Conclusions: New scoring system can predict difficult cases reliably. Scoring patients preoperatively can decrease intra-op difficulties. Patients can pre-op be informed about possible risk of conversion to open cholecystectomy.

Predictors of Difficult Laparoscopic Cholecystectomy on Humanitarian Missions to Peru Difficult Laparoscopic Cholecystectomy in Surgical Missions

Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstone disease. On short-term surgical missions (STSMs), it is unclear what factors can predict safety of LC. This study evaluates patient risk factors of difficult LC in Northern Peru, towards optimizing outcomes. A retrospective review was performed of patients who underwent LC during short-term surgical missions to Peru from 2016-2019 under the International Surgical Health Initiative (ISHI). Difficult and routine LC groups were compared for: age, weight, gender, symptom duration, pain on presentation, history of abdominal or pelvic surgery, diabetes and hypertension. 68 of 194 patients underwent LC; 42 patients (62%) were classified as difficult with OR (operating room) time > 70 min (90%), 2 cases converted to open (5%) and 2 aborted cases (5%). Higher weight class was found to correlate with difficult LC. Increased patient weight was correlated to longer operative time during STSMs. Patients undergoing LC must be selected carefully to mitigate risks of difficult operations on STSMs.

Preoperative prediction of difficult laparoscopic cholecystectomy based on diffusion-weighted magnetic resonance imaging.

Laparoscopic cholecystectomy is a common surgery with a varying difficulty level. Difficult laparoscopic cholecystectomy may be experienced by many surgeons. If difficult procedures are predicted preoperatively, surgeons may be able to plan the surgical approach and treatment accordingly. Studies have reported using blood and clinical imaging data to predict difficult cholecystectomy. However, to our knowledge, no studies have reported using MRI. The purpose of this study was to evaluate the usefulness of MRI as a predictor of difficult laparoscopic cholecystectomy. We retrospectively evaluated 25 patients with cholecystitis or biliary colic who had undergone diffusion-weighted whole-body imaging before laparoscopic cholecystectomy. The apparent diffusion coefficient value of the cystic duct was measured and its relationship with operative time and blood loss was examined to assess the capacity of diffuse-weighted whole-body imaging to predict difficult cholecystectomy. Further, we collected blood data and compared its usefulness as a predictor. The apparent diffusion coefficient value of the cystic duct was significantly lower in patients with difficult laparoscopic cholecystectomy than in those with non-difficult procedures (P= .00007). White blood cell count and serum C-reactive protein level were significantly higher in patients with difficult cholecystectomy than in those with non-difficult procedures (P= .035, .030). In the receiver operating characteristic analysis, the apparent diffusion coefficient value was the best predictor. Our results suggest that the apparent diffusion coefficient value of the cystic duct is a predictor of difficult laparoscopic cholecystectomy. In the future, it may be useful to study changes in coefficient values over time to determine optimal surgical timing.

Evaluation the efficacy of scoring method for pre-operative prediction of difficult laparoscopic cholecystectomy

Laparoscopic Cholecystectomy the procedure of choice for symptomatic Cholelithiasis. Preoperative prediction of a difficult cholecystectomy and the risk of conversion is of great help both to the patient who can plan his work and the surgeon who can also schedule his time and team accordingly. Randhawa developed a scoring method on the basis of History, Clinical Examination and Sonological findings to predict difficult Laparoscopic Cholecystectomy preoperatively. We are conducting this study to evaluate the efficacy of Randhawa scoring method in pre-operative prediction of difficult laparoscopic cholecystectomy and to identify the predictors of difficult laparoscopic cholecystectomy which will help the surgeon to provide better surgical care to the patient.

The role of C-reactive protein as a predictor of difficult laparoscopic cholecystectomy or its conversion

Background: Laparoscopic cholecystectomy (LC) can be the easiest or the most difficult laparoscopic operation. Conversion to open surgery has been a traditional marker of difficult LC. Recent studies have shown that C-reactive protein (CRP) may be helpful to surgeon in knowing the pathological condition of gall bladder before removal. Aim of this study was to evaluate the role of CRP as a predictor of difficult LC or its conversion.Methods: This study was done from 1 march 2016 to may 2017 in department of general surgery, SMS hospital Jaipur, under single unit. All patients with cholelithiasis admitted in single unit of SMS hospital undergoing LC were included in this study. Exclusion criteria were high BMI (>35), proven congenital anomaly of gall bladder, previous abdominal surgery, any conditions increasing CRP and immunocompromised patients. CRP was done for each patient.Results: Mean age of our 148 patients was 50.41 years. Female to male ratio was 4.28:1. Mean CRP was 22.2±18.2 mg/dl for simple cholecystectomy, 46.5±32.0 mg/dl for difficult cholecystectomy and 83.6±22.4 mg/dl for laparoscopic converted to open cholecystectomy, which was statistically significant (p value 0.0002).Conclusions: CRP is a potent predictor of difficult laparoscopic cholecystectomy and its conversion preoperatively. Patients with preoperatively high CRP have higher chance of complication intraoperative and high chances of conversion to open.

Prediction of difficult laparoscopic cholecystectomy while working up the patient for surgery

Introduction: Laparoscopic cholecystectomy [LC] has established itself as standard of care for gallstone disease. With the wide availability of expertise, complication rate and conversion rate both are coming down. Coupled with increase in patient awareness and easy accessibility of information, it is becoming increasingly difficult for surgical team to explain complication arising following surgery. A preoperative prediction can help ease doctor-patient relationship. Objective: To find out the predictors of difficult laparoscopic cholecystectomy while investigating the patient for surgery. Patient and methods: We selected 125 patients based on convenient sampling who underwent LC. A Likert type questionnaire was used to assess the difficulty. Weighted difficulty score [WDS] was calculated as the sum of product of parameter response and difficulty response score [WDS= ∑ (PR x DRS)]. Mean WDS was then compared against preoperative investigation findings. Results: Mean WDS was found to increase with raised leukocyte count as well as with altered liver function tests. Thickened gallbladder wall in ultrasonography had a positive correlation with difficulty in surgery but no association was found with the pericholecystic fluid. A larger size of stone, stone impacted at neck and a larger size of the impacted stone were all had a significant positive association with difficult LC but number of stones in GB had no impact on difficulty during surgery in our study. Altered liver echotexture and a contracted GB were the other factors which can predict a possible difficulty during LC. Conclusion: A careful watch on investigation which include leukocyte count, liver function tests and preoperative ultrasonography can help predict the difficulty, a possibility of conversion as well as complications. A discussion of these events with the patients and their relatives can create an atmosphere of mutual trust and better prepare to overcome of untoward events.

C-Reactive Protein as a Predictor of Difficult Laparoscopic Cholecystectomy in Patients with Acute Calculous Cholecystitis: A Multivariate Analysis.

Laparoscopic cholecystectomy (LC) is the treatment of choice for mild and moderate acute cholecystitis. The aim of this study was to analyze the utility of C-reactive protein (CRP) as a predictor of difficult laparoscopic cholecystectomy (DLC) in patients with acute cholecystitis. We conducted a prospective study. All patients included were treated with emergency LC. Patients were analyzed as DLC and nondifficult laparoscopic cholecystectomy (NDLC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables were statistically significant in predicting a DLC. Two different models were analyzed. A total of 66 patients were included (37.9% DLC versus 62.1% NDLC). Ideal cutoff point for CRP was calculated as 11 mg/dL, with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for predicting DLC being 92% (95% CI 75-97.8), 82.9% (95% CI 68.7-91.5), 76.7%, and 94.4%, respectively. In the first model multivariate analysis, age >45 years, male sex, gallbladder wall thickness ≥5 mm, and pericholecystic fluid collection were significant predictors of DLC, with an area under the curve (AUC) of 0.89. In the second model multivariate analysis, only CRP ≥11 (odds ratio, OR = 17.9, P = .013) was significant predictor of presenting DLC, with an AUC of 0.96. Preoperative CRP with values ≥11 mg/dL was associated with the highest odds (OR = 17.9) of presenting DLC in our study. This value possesses good sensitivity, specificity, PPV, and NPV for predicting DLC in our population with acute calculous cholecystitis.

HsCRP levels as predictor of difficult laparoscopic cholecystectomy- current status evaluation experience in a teaching institution

Background: CRP, an acute phase reactant, is known to increase up to 1000 folds following inflammation and/or infection, but it’s utility as a significant predictor of difficult LC or need for conversion to OC still remains controversial. Limited studies on levels of hsCRP and its association with difficult cholecystectomy are available in literature, especially in Indian context. It is hypothesized that levels of hsCRP pre-operatively for a given population or an individual patient if high would help a surgeon anticipate better a difficult LC, avoid excessive intra-operative manipulations, go for conversion early, reduce time of surgery and hence also minimise post-operative complications.Methods: The present included 30 clinically diagnosed ‘cholecystitis with cholelithiasis’ patients, and 30 healthy individuals. For accurate comparison of hsCRP levels, a fasting and post-operative, 6 and 12 hours, blood samples were analyzed by ELISA test. Pre-and post-operative hsCRP values were recorded and analyzed using multi-user licensed SPSS- Version 21.0.Results: The mean value of hsCRP in controls was 1.43mg/L. In study group, in pre-operative serum samples, the concentration was 20.46 mg/l. At 6 and 12 hours post-operative periods, the mean values observed were 24.4mg/L and 23.7 mg/L respectively. Compared with controls, the mean values are fairly high and statistically also significant (p-values <0.0001). For the study group comparison of hsCRP value pre-operative and post-operatively 6 hours, using Wilcoxon Signed Rank Test has given the p-value <0.001 indicating that the increased hsCRP concentration in patients’ circulation is highly significant as a predictor of difficult laparoscopic cholecystectomy. Similarly, Comparison of hsCRP value pre-operative and post-operative 12 hours, using Wilcoxon Signed Rank Test revealed the p-value <0.007 showing it as highly significant and a predictor of difficult LC requiring conversion. The preoperative value of 20.46% is significant for an individual planned for LC who may require conversion.Conclusions: The preoperative hsCRP value of 20.64mg/L, as per our study results, can be relied upon as predictors of difficult LC and/or need for conversion not only in the study group in the given population but also in individual cases. Such a value of 20.64mg/L is definitely important for an individual case management. Knowing the preoperative values beforehand and if found high, it places a surgeon on a cautious note to avoid too much of LC manipulations intra-operatively, take an early decision to go for conversion, reduce the time of surgery, minimise post-operative complications and hence also morbidity.

Prediction of difficulties during laparoscopic cholecystectomy by preoperative clinical examination and ultrasonography

Background: Cholelithiasis (gall stone disease) is a well-known disease worldwide. Ultrasonography is the most common screening test for cholecystitis and cholelithiasis. Laparoscopic Cholecystectomy is considered the treatment of choice for symptomatic gall stone disease. It is important to know the different clinical, radiological parameter and specific predictor that give some prediction of difficult LC. The aim of this study was to predict the difficulty of LC and the possibility of conversion to OC before surgery using the clinical and ultrasonographic criteria in our set up.Methods: The present study was carried out in the Department of surgery, Sarojini Naidu Medical College Agra, from November 2014 to October 2016. A total of 210 patients were enrolled for the laparoscopic cholecystectomy. All patients who were included in the study were undergone detailed history and clinical examination. A number of clinical and ultrasonographical parameters were noted.Results: Amongst the 210 patients admitted for laparoscopic cholecystectomy, 21 (10%) were male and 189 (90%) female, with age ranging from 12–60 years. The conversion rate in our study was 4.5% (9 of 210). In our study significant pre-operative factors which increased the conversion rate to open cholecystectomy includes male gender, obesity, abdominal scar of previous surgery, contracted and thickened gall bladder and patients having stone impacted at the neck of gall bladder.Conclusions: From this study, we conclude that preoperative ultrasonography is a good predictor of difficult laparoscopic cholecystectomy in the majority of cases and should be used as a screening procedure.

Preoperative Predictors of Difficult Laparoscopic Cholecystectomy

Preoperative Predictors of Difficult Laparoscopic Cholecystectomy

Evaluation of preoperative predictive factors that determine difficult laparoscopic cholecystectomy

Background: Cholelithiasis is the most common biliary pathology. Gallstones are present in 10 to 15% of the general population and asymptomatic in the majority (>80%). The prevalence of gallstone varies widely in different parts of the world. In India it is estimated to be around 4%. Since laparoscopic cholecystectomy is the most common procedure done now days we undertook a study to evaluate factors determining difficult laparoscopic cholecystectomy. The objective of the study was to evaluate preoperative data that can serve as predictors of difficult laparoscopic cholecystectomy and help in planning of surgery. Methods: Patients presenting with upper abdominal discomfort and sonographically confirmed cholelithisis were studied in terms of several clinical factors and scoring system was devised. Based on scoring system patients were categorised and evaluated post operatively. Results: In present study prior history of hospitalisation (p 27.5 (p<0.01), thickened GB wall (p<0.001) were found to be significant predictors of difficult laparoscopic cholecystectomy. Remaining parameters like age, sex, impacted stone and pericholecystic collection were not found significant predictors of difficult laparoscopic cholecystectomy. Conclusions: Difficult laparoscopic cholecystectomy can be predicted preoperatively based on parameters used in the study. Knowledge of these factors for difficult laparoscopic cholecystectomy could help surgeons during pre-operative assessment and improve the informed consent.

Study of 292 patients for prediction of difficult laparoscopic cholecystectomy using detailed history, clinical and radiological parameters

Background: Now laparoscopic Cholecystectomy is one of most commonly performed procedure by General surgeon, and also of very much of interest for trainee to learn basic of laparoscopic procedure. On the basis of history, patient profile, clinical examination and radiological examination, we tried to select the cases that may help to predict the difficult GB. Methods: This study was conducted in Department of General Surgery Mahatma Gandhi Medical College and Hospital, Jaipur from Aug 2013 to Aug 2015 and total 292 enrolled for this study. In our institute we defined DLC according to operating time which was >75 min from incision and veress needle insertion to GB extraction. Results: In our study out of 292 pt we were found 72 pts as difficult GB. Detailed study of these patients clearly shows that pt. of male, higher side of age, increase duration of symptoms with multiple stone which are small in size have more chance of difficulty in laparoscopic Cholecystectomy because these patients have more repeated attacks of cholecystitis silently or clinically detected previously. Conclusions: From this study we conclude that pre-operative radiological investigations (USG, MRCP) are no doubt good predictors of difficult laparoscopic Cholecystectomy in majority of cases and should be used as a screening procedure but more attention should be given to demographic data, history and clinical examination to predict the difficult LC.

Is C-reactive protein the single most useful predictor of difficult laparoscopic cholecystectomy or its conversion? A pilot study.

INTRODUCTION:Both converted and difficult laparoscopic cholecystectomies (LC) have impact on operating time and training of juniors. The aim of this study is to evaluate parameters that predict difficult LC or conversion (C), and find predictive values for different cut-off points of C-reactive protein (CRP) for conversion.MATERIALS AND METHODS:A retrospective cohort study of cholecystectomies performed from January 2011 to December 2012 at NHS trust was undertaken. Association of intra-operative difficulties or conversion with the following factors was studied: Age, gender, CRP, white blood cell count (WBC), history of pancreatitis, and endoscopic retrograde cholangiopancreatography (ERCP).RESULTS:Two hundred and ninety one patients were analysed (222 laparoscopic, 45 difficult LC and 24 C). Only 141 patients had a recorded CRP. Median CRP was highest for patients who were converted (286.20) compared to those who had difficult LC (67.40) or LC (7.05). Those patients who did not have preoperative CRP (8/150, 5.3%) had less chance of conversion than those who had CRP (16/141, 11.34%) (P = 0.063). Patients with CRP of ≤220 (3/91, 3.2%) had significantly less chance of conversion than those with CRP >220 (13/21, 61.9%) (P < 0.001). High preoperative CRP, WBC count and ERCP, were predictors of conversion. These factors were only marginally better than CRP alone in predicting conversion.CONCLUSION:CRP can be a strong predictor of conversion of LC. Further validation of the results is needed.

Grading operative findings at laparoscopic cholecystectomy- a new scoring system.

IntroductionVariation in outcomes from surgery is a major challenge and defining surgical findings may help set benchmarks, which currently do not exist in laparoscopic cholecystectomy. This study outlines a new surgical scoring system incorporating key operative findings.MethodsEnglish language studies (from January 1965 to July 2014) pertaining to severity scoring and predictors of difficult laparoscopic cholecystectomy were searched for in PubMed, Embase and Cochrane databases using the search terms ‘Laparoscopic cholecystectomy or Lap chole’ and/or ‘Scoring Index or Grading system or Prediction of difficulty or Conversion to open’ in various combinations. Cross-referencing from papers retrieved in the original search identified additional articles.ResultsSixteen published papers report a gallbladder (GB) scoring system, but all relate to pre-operative clinical and imaging findings, rather than operative findings. The current scoring system, using operative findings incorporates the appearance of the GB, presence of GB distension, ease of access, potential biliary complications and time taken to identify cystic duct and artery. A score of <2 would imply mild difficulty, 2–4 moderate, 5–7 severe and 8–10 extreme.ConclusionThis paper reports one of the first operative classifications of findings at laparoscopic cholecystectomy. It has the potential to allow benchmarks for international collaboration of operative and patient outcomes in patients undergoing laparoscopic cholecystectomy.