Pre-Operative Predictors of Difficult Laparoscopic Cholecystectomy; Comparisons of Two Scoring Systems. A Single Center Prospective Study”

Abstract

INTRODUCTION:Laparoscopic Cholecystectomy has evolved as the standard of care for the treatment of Gall Stone disease over the past decade. Several patient and procedure related factors have been implicated in setting of failure to complete the procedure by minimal invasive method and various scores have been developed to precisely predict a Difficult Laparoscopic Cholecystectomy. AIMS: The present study was conducted to ascertain various patient related preoperative risk factors for conversion of laparoscopic Cholecystectomy to open method and to validate the Risk Score for conversion. SETTINGS & DESIGN: A total of 100 patients with diagnosis of Gall Stone Disease admitted to our surgical Unit between October 2011 and April 2013 were assessed for various pre-determined risk factors and were accordingly categorized into three levels of anticipated difficulty according to RSCLO and our new scoring system. The patients were then subjected to Laparoscopic Cholecystectomy by the same surgical team and the procedure was then graded as difficult or not according to the pre-defined criteria. The findings were analysed by appropriate statistical analysis. RESULTS: Presence of factors like Male sex, history of attacks of acute cholecystitis, increased GB wall thickness, presence of supra-umbilical abdominal scar, obesity and a contracted GB were associated with a significantly higher rate of conversion to open method. RSCLO was found to correlate better with the outcome in this setting than our New Scoring System. CONCLUSION: Several patient related factors may be helpful in predicting a Difficult Laparoscopic Cholecystectomy pre-operatively. RSCLO Scoring system may be useful as a pre-operative tool to predict intra-operative difficulty during LC. KEY WORDS: Difficult laparoscopic Cholecystectomy, RSCLO, pre-operative factors. INTRODUCTION:Laparoscopic Cholecystectomy has evolved as the Gold Standard procedure for treatment of Gall Stone Disease. In approximately 2-15% of the patients failure to achieve the desirous aim mandates the conversion of the procedure to Open Method 1. Various patient and procedural related factors have been implicated for this conversion. Extensive studies and various protocols have also been suggested to identify 'Difficult Laparoscopic Cholecystectomy' preoperatively. Previous attacks of acute cholecystitis, GB wall thickness, inability to delineate the anatomy and previous abdominal surgery are some of the factors that have been identified as potential risk factors for the conversion. The present study was conducted to ascertain patient related pre-operative risk factors for conversion of laparoscopic Cholecystectomy to open method and to validate the Risk Score for conversion.

Preoperative Prediction of the Difficulty of Laparoscopic Cholecystectomy

“…Vivek and colleagues traced difficulty as in creating pneumoperitoneum, accessing peritoneal cavity, releasing adhesions, identifying anatomy and extracting the gall bladder [13]. Previous attacks of acute cholecystitis, GB wall thickness, inability to delineate the anatomy and previous abdominal surgery are some of the factors that have been identified as potential risk factors for the conversion [14]. Accordingly in concordance with these studies [12][13][14] our data showed that burn cicatrization and supra-umbilical surgical scars led to difficult creation of pneumoperitoneum and difficult accessing peritoneal cavity.…”

“…Score of (0-5) indicates an easy approach while score of (6-10) indicates difficult approach and very difficult approach is observed with score of (11)(12)(13)(14)(15).…”

Evaluation of difficulties in laparoscopic cholecystectomy

“…Surge and coworkers offered a scoring system based on operative findings and the degree of cholecystitis in order to outline key operative findings [22]. Other authors were focused to establish predictive factors for difficult LC and conversion [23,24], or only for conversion [25], assuming that nowadays all cholecystectomies are treated laparoscopically. We tried to establish a simple model of prediction, which was then validated.…”