Predicting difficulty in laparoscopic cholecystectomy preoperatively using a scoring system

Mohammed Raza, Venkata Rajeev M.


Background: Laparoscopic cholecystectomy (LC), one of the most commonly performed surgical procedures worldwide. Preoperative assessment of difficulty is needed for frequent procedures such as LC in order to avoid complications, preparedness and to guarantee an efficient course of surgery. But there is no scoring system available to predict the difficulty preoperatively.

Methods: In our study we have tried to predict a difficult LC preoperatively using a modified scoring system proposed by Randhawa et al. Patients diagnosed to have GB stones requiring LC were evaluated with following factors age, gender, duration of illness, h/o previous GB disease, underwent ERCP, BMI, abdominal scar whether infra umbilical or supraumbilical, palpable gallbladder, sonographic findings - gall bladder wall thickness, pericholecystic collection, impacted stone. Various clinical and radiological and intra-operative parameters were scored. Procedure is graded based on individual surgeon’s opinion as easy/difficult/very difficult. The parameters were analyzed to find their correlation to predicting difficult LC. Degree of difficulty was analyzed.

Results: Preoperative scoring system proposed by Randhawa et al that we modified was found to be appropriate for predicting operative outcome in LC, having overall p value for the scoring system of <0.001, with sensitivity of 90.9, specificity of 73.1% and area under RoC of 0.876. In present study, palpable gall bladder, history of previous cholecystitis, and the radiological parameters i.e. GB wall thickness, pericholecystic fluid and impacted stone to be statistically significant.

Conclusions: Present modified Randhawa and Pujahari scoring system is valuable and appropriate for predicting operative outcome in laparoscopic cholecystectomy. This, in turn, facilitates better preparedness.


Difficult, Lap cholecystectomy, Prediction, Scoring

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Randhawa JS, Pujahari AK. Preoperative prediction of difficult lap chole: a scoring method. Indian J Surg. 2009 Aug 1;71(4):198-201

Al-Mulhim AA. Male gender is not a risk factor for the outcome of laparoscopic cholecystectomy: A single surgeon experience. Saudi J Gastroenterol. 2008 Apr;14(2):73-9.

Reinders JS, Gouma DJ, Heisterkamp J, Tromp E, van Ramshorst B, Boerma D. Laparoscopic cholecystectomy is more difficult after a previous endoscopic retrograde cholangiography. HPB. 2013 Mar 1;15(3):230-4.

Mann K, Belgaumkar AP, Singh S. Post–Endoscopic Retrograde Cholangiography Laparoscopic Cholecystectomy: Challenging but Safe. JSLS. 2013;17:371-5.

Nidoni R, Udachan TV, Sasnur P, Baloorkar R, Sindgikar V, Narasangi B. Predicting difficult laparoscopic cholecystectomy based on clinicoradiological assessment. JCDR. 2015 Dec;9(12):PC09.

Gupta N, Rajan G, Arora MP, Goswami B, Chaudhary P, Kapur A, et al. Validation of a scoring system to predict a difficult laparoscopic cholecystectomy. Int J Sur. 2013;11(9):1002-6.

Kama NA, Kologlu M, Doganay M, Reis E, Atli M, Dolapci M. A risk score for conversion from laparoscopic to open cholecystectomy. Am J Surg. 2001 Jun 1;181(6):520-5.

Agrawal N, Singh S, Khichy S. Preoperative prediction of difficult laparoscopic cholecystectomy: a scoring method. Nigerian J Surg. 2015;21(2):130-3.

Kanakala V, Borowski DW, Pellen MG, Dronamraju SS, Woodcock SA, Seymour K, et al. Risk factors in laparoscopic cholecystectomy: a multivariate analysis. Int J Surg. 2011 Jan 1;9(4):318-23.

Lipman JM, Claridge JA, Haridas M, Martin MD, Yao DC, Grimes KL, et al. Preoperative findings predict conversion from laparoscopic to open cholecystectomy. Surg. 2007 Oct 1;142(4):556-65.

Dhanke PS, Ugane SP. Factors predicting difficult laparoscopic cholecystectomy: A single-institution experience. Int J Students’ Res. 2014 Jan 1;4(1):3.

Nachnani J, Supe A. Pre-operative prediction of difficult laparoscopic cholecystectomy using clinical and ultrasonographic parameters. Indian J Gastroenterol. 2005;24(1):16-8.

Vivek MA, Augustine AJ, Rao R. A comprehensive predictive scoring method for difficult laparoscopic cholecystectomy. J Minimal Access Surg. 2014 Apr;10(2):62-7.

Akyurek N, Salman B, Irkorucu O, Tascilar O, Yuksel O, Sare M, et al. Laparoscopic cholecystectomy in patients with previous abdominal surgery. JSLS. 2005 Apr 1;9(2):178-83.

Schrenk P, Woisetschläger R, Rieger R, Wayand WU. A diagnostic score to predict the difficulty of a laparoscopic cholecystectomy from preoperative variables. Surg Endoscopy. 1998 Feb 1;12(2):148-50.

Lal P, Agarwal PN, Malik VK, Chakravarti AL. A difficult laparoscopic cholecystectomy that requires conversion to open procedure can be predicted by preoperative ultrasonography. J Soc Laparoendoscopic Surg. 2002 Jan;6(1):59-64.