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A clinical study to determine predictive factors for difficult laparoscopic cholecystectomy

Madan Mohan Mudgal, Naveen Kushwah, Raghvendra Singh, Himanshu Gehlot.

Abstract
Background: Forecast of a difficult laparoscopic cholecystectomy (LC) can help the surgeon as well as the patient to prepare better for any intraoperative risk and its effective management.

Objectives: The objectives of this study were to assess the clinical and radiological parameters for predicting the difficult LC and its conversion.

Materials and Methods: Hundred patients of gallstone disease undergoing LC were studied from September 2014 to August 2015. All the patients underwent detailed pre-operative history, clinical examination, laboratory investigations, and transabdominal sonography. The study group was subjected to LC using the general anesthesia. Peroperative degree of difficulty was evaluated depending on objective variables which included the presence of adhesions at Calot’s triangle and between omentum and gallbladder (GB), obvious injury to GB, biliary ducts, bowel, diaphragm or other abdominal viscera, stone/biliary spillage, injury to vessels, need of conversion to open procedure (OP), and post-operative complications in the early post-operative period arising as a result of intra-operative difficulty, for example, biliary fistula, biloma, biliary peritonitis, and bowel injury unmasking after surgery.

Results: Female (n = 82) preponderance was observed. Mean age and body mass index (BMI) was 38.60 ± 11.62 years and 27.29 ± 3.59 kg/m2, respectively. The incidence rate of difficult LC was 34%, whereas conversion rate to open cholecystectomy was 11%. Rate of difficult LC was significantly more in patients with a history of previous abdominal surgery (n = 34, P < 0.001), tenderness in right hypochondrium (n = 31, P = 0.003), and thickening of GB (n = 19, P < 0.001), whereas conversion to OP was significantly high in patients with thickening of GB (n = 19, P = 0.001) and distended or contracted GB (n = 18, P = 0.001). Most common intra-operative findings which made the procedure difficult was dense adhesions at Calot’s triangle (n = 32). Most common reason for conversion to OP was stone/biliary spillage (36.4%).

Conclusion: BMI, history of previous abdominal surgery, tenderness in the right hypochondrium, and thickening of the GB are the significant predictive factors for difficult LC, whereas conversion to OP was high in patients with thickening of GB and GB contracted.

Key words: Body Mass Index; Laparoscopic Cholecystectomy; Conversion; Open Procedure



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