Preoperative Factors Associated with Difficult Laparoscopic Cholecystectomy

Background : Laparoscopic cholecystectomy is the gold standard treatment for gallstones. Laparoscopic cholecystectomy provides improved cosmesis and improved patient satisfaction as compared with open cholecystectomy. Gall stones are commonly observed, and laparoscopic cholecystectomy has become the standard treatment for this disease. Objective: To determine the frequency of difficult laparoscopic cholecystectomy (based on duration of surgery and conversion) and to identify pre- operative factors associated with it. Material & Methods: presence of factors were collected and difficulty in laparoscopic cholecystectomy was noted. All the collected data was entered and analyzed on SPSS version 16. Results : In our study the average age of the patients was 46.52±15.59 years, average duration of surgery of the patients was 18.74±8.84 minutes. Our 2 (2%) patients needed conversion to open cholecystectomy for the treatment and difficult laparoscopic cholecystectomy, based on operative time, was noted in 30 (30%) of the patients. Conclusion : The difficult laparoscopic cholecystectomy observed in approximately one third of the patients. The clinical assessment is a useful method for the assessment of difficult laparoscopic cholecystectomy and for planning safe surgery pre-operatively. Preoperative


Introduction
Laparoscopic cholecystectomy is the gold standard treatment for gallstones. Preoperative estimation of difficulty level can help plan a safe surgery with minimal complications. Cases with anticipated higher degree of difficulty can be planned for open cholecystectomy or be referred to a more experienced surgeon [1]. Vivek and associates assessed difficulty level in creating pneumoperitoneum, getting to peritoneal cavity, adhesiolysis, distinguishing anatomical structures and removing the gall bladder. Age >65 years, male gender, recurrent attacks, history of previous abdominal surgery, deranged liver function tests and serum amylase levels and distended gall bladder with pericholecystic inflammation on ultrasonography, were identified to be some of the factors associated with difficult laparoscopic cholecystectomy in their study [2]. Previous history of acute cholecystitis, acute cholecystitis on admission, > 5 recurrent attacks of pain that lasted more than 4 hours, diabetes mellitus, duration of symptoms longer than 36 months, gallbladder wall thickness 4mm, calculus size > 2cm and presence of pericholecystic fluid collection on ultrasonography were significantly related to difficulty in laparoscopic cholecystectomy as concluded by Stanisic and collegues [3]. Few studies have assessed difficulty level based on deviation from the standard operative time [4][5]. Joshi at al predicted difficult laparoscopic cholecystectomy using a scoring system including history, clinical and sonographic parameters and predicted 78% of the cases to be easy and 22% as difficult, while, per-operatively, 74% of the cases were easy and 26% were not [4].  [5]. Our aim is to determine the frequency of difficult laparoscopic cholecystectomy (based on duration of surgery and conversion) and to identify preoperative factors associated with it. Our study will contribute to the literature. Hence, with the help of this study we would identify the preoperative factors in our setting, which could lead to difficult laparoscopic cholecystectomy and help plan the safe surgery and post-operative care accordingly, minimizing the risk of complications.

Materials and Methods
This Cross-sectional study was done in the department of

Results
In this study total 100 patients were enrolled.    The study results showed that the gall bladder wall thickness was found in 25 (25%) patients, pericholecystic fluid found in 12 (12%) patients and multiple stones were noted in 86 (86%) patients (

Discussion
Laparoscopic cholecystectomy being the gold standard treatment of symptomatic cholelithiasis preoperative prediction of the risk of conversion is an important aspect of planning laparoscopic surgery.
It is important to predict difficult laparoscopic cholecystectomy preoperatively so that senior surgeons can be requested to be present during surgery rather than less experienced junior surgeon prolonging the surgery which may lead to intraoperative complications. In preoperatively predicted to be conversion, early decision of conversion can be made so as to avoid unnecessarily prolonging the surgery and to prevent complications [6]. Some of the studies are discussed below showing the results in favor of our study as. Ravindra Nidoni et al. [6] showed that the total leukocyte count >11000, more than 2 previous attacks of cholecystitis, gall bladder wall thickness of >3mm and Pericholecystic collection were all statistically significant for predicting the difficult laparoscopic cholecystectomy and its conversion. Sanabria et al. found in their study of 628 patients that patients with multiple attacks (ten or more) were significantly associated with conversion [10]. Reported in a study of 300 patients assessing 24 variables for conversion that patients with history of acute chole cystitis within the last 3 weeks were at increased risk of conversion [11]. Many studies have identified raised WBC as a risk factor for predicting conversion [11][12][13][14]. Gall bladder wall thickness has been identified as a risk factor for conversion in many of the studies. The thickness of gall bladder associated with conversion varies from study to study. It was 3mm [15][16], 4mm [17]. While in most of the studies age was considered as a risk factor for conversion [12,13,15,17,18,19].
May be the reason is that they use some other value of age for cut off. Our study and some other authors did not notice age to be associated with conversion rate [20][21]. Male sex as an independent risk for conversion is controversial. Few series have shown it to be an independent risk factor [10,16,17,20,[22][23][24]. However, like our study findings Liu et al. did not notice sex to be associated with conversion [18]. Atul Kumar Gupta et al. [25]