Prediction of difficult laparoscopic cholecystectomy: An observational study

Robotic versus laparoscopic cholecystectomy for difficult gallbladders: an observational study of tertiary centre cases

BACKGROUND

Although laparoscopic cholecystectomy (LC) is considered a low-risk procedure, intraoperative bleeding, bile duct injury and bile leak occur frequently in the 'difficult' gallbladder. Robotic cholecystectomy (RC) can overcome difficulties related to poor vision and instrumentation in difficult cases to avoid intraoperative complications and conversion to open surgery. The aim of the study was to evaluate the outcomes of laparoscopic and robotic cholecystectomy in patients with difficult gallbladders referred to a tertiary HPB centre.

METHODS

We conducted a retrospective review of all patients referred to a senior hepatobiliary and pancreatic surgeon with a 'difficult' gallbladder between December 2013 and March 2024. Primary outcomes were conversion to open procedure, and 30-day post-operative complications.

RESULTS

A total of 88 difficult gallbladder cases (n = 35 laparoscopic, n = 53 robotic) were referred to a tertiary HPB centre during the study period, consisting of 21.7% of cholecystectomies (n = 404). The total complication rate (14.3% vs 3.8%, OR 4.25, 95% CI 0.77-23.28, p = 0.0951) and conversion rate (8.6% vs 0.0%, OR 11.52, 95% CI 0.57-230.32, p = 0.109) were both higher in the laparoscopic group, but these differences were not statistically significant. The median operative time was significantly higher in the laparoscopic group (108.5 min vs 50.0 min, p = 0.001).

CONCLUSIONS

Both robotic and laparoscopic cholecystectomy are viable approaches in difficult gallbladder cases, with robotic cholecystectomy being associated with potentially fewer complications and conversions to open surgery. Pre-operative referral of patients with difficult gallbladders and the intra-operative abandonment of difficult cases can both be considered safe exit strategies for difficult gallbladder cases.

Development and validation of a radiologically-based nomogram for preoperative prediction of difficult laparoscopic cholecystectomy

Background

Preoperative prediction of difficult laparoscopic cholecystectomy (DLC) remains challenging, as intraoperative anatomical complexity significantly increases complication risks. Current studies have not reached consensus on definitive risk factors for DLC.

Materials and methods

This retrospective study aimed to identify DLC risk factors and develop a predictive model. We analyzed clinical data from 265 patients undergoing laparoscopic cholecystectomy (LC) at the Department of General Surgery, Shijiazhuang People's Hospital, between September 2022 and June 2024. Risk factors were explored through least absolute shrinkage and selection operator (LASSO) regression, multivariate analysis, and receiver operating characteristic (ROC) curves, with a nomogram constructed for prediction.

Results

Among 265 eligible patients, four independent risk factors were identified: thickness of gallbladder wall (p = 0.0007), cystic duct length (p < 0.0001), cystic duct diameter (p < 0.0001), and gallbladder neck stones (p = 0.0002). The nomogram demonstrated strong predictive performance, with an area under the curve (AUC) of 0.915 in the training cohort and 0.842 in the validation cohort. Calibration curves indicated excellent model fit.

Conclusion and discussion

The proposed predictive model integrating gallbladder neck stones, thickness of gallbladder wall, cystic duct length, and cystic duct diameter may assist surgeons in preoperative DLC risk stratification. Further validation through multicenter prospective studies is warranted.

Comparison of Surgical Outcomes of Emergent Laparoscopic Cholecystectomy for Acute Cholecystitis Between Attending Surgeons and Residents: A Retrospective Study in Single Medical Center

Background: With improvements in skills and evidence of safety, emergent laparoscopic cholecystectomy is routinely performed for acute cholecystitis, if indicated, at our hospital. However, resident operations are concerned with the dilemmas of training programs and patient safety. Hence, our aim was to clarify the safety and feasibility of emergency laparoscopic cholecystectomy performed by attending surgeons and residents. Materials and Methods: Our study was a retrospective review of 923 patients, who underwent laparoscopic cholecystectomy between January 2021 and June 2022 at our hospital. We excluded combined surgery, single-port methods, laparoscopic common bile duct exploration, elective surgery, and patients with Mirizzi symptoms. Of the 191 patients who underwent emergency laparoscopic cholecystectomy, 118 were operated on by residents, and 73 were operated on by attending surgeons. Patient demographics, surgical and postoperative outcomes, and length of hospital stay were compared between the groups. Results: No significant differences were observed in sex, age, body mass index (BMI), or surgical history. Older age (60 versus 52 years) and higher BMI (26.29 versus 25.46) were observed in the attending group, and the severity was greater than that in the resident group. No significant differences were observed in the operative results, including mortality (both groups, n = 0), morbidity, blood loss, or length of stay. However, the operation time was significantly shorter in the attending group obviously (86.41 versus 117.89 minutes, P < .0001) significantly. Conclusion: Emergent laparoscopic cholecystectomy for acute cholecystectomy performed by a resident under supervision appears feasible and safe. The resident operator was associated with increased operative times, however, not complications. This study confirms that residents can also finish surgery in precisely selected cases, and the more important concept is knowing the limits of asking for help.

Frequency and Predictors of Conversion From Laparoscopic to Open Cholecystectomy: A Single-Center Observational Study

OBJECTIVE

The study aimed to investigate the rate of conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) in our population and determine the potential risk factors associated with it. Understanding these factors helps surgeons predict complex cases and plan surgeries, reducing patient risks and improving outcomes.

METHODOLOGY

A cross-sectional observational study was conducted from June 1, 2022, to May 31, 2023, at Hayatabad Medical Complex, Peshawar, on 349 patients undergoing elective LC. Data on demographics, clinical history, laboratory values, and imaging findings were recorded using a standardized proforma. Intraoperative findings, surgical outcomes, and complications were noted, with statistical analysis performed using IBM SPSS Statistics for Windows, Version 23.0 (Released 2015; IBM Corp., Armonk, New York, United States). Chi-squared, Mann-Whitney U, and logistic regression tests assessed the associations and risk factors of conversion to open surgery.

RESULTS

 The rate of conversion from LC to OC was found to be 13 (3.7%). The multivariate analysis revealed several significant risk factors associated with the conversion. These included male gender, history of jaundice due to gallbladder stones, history of pancreatitis, gallbladder wall thickness greater than 3 mm, white blood cell counts greater than 1000 per microliter of blood, difficulty in handling the gallbladder with instruments intraoperatively, and dense adhesions with surrounding tissues (p<0.05). The risk factor summation pyramid showed a sensitivity of 84.6% and a specificity of 63.8% in predicting the likelihood of conversion, emphasizing the importance of considering each risk factor individually.

CONCLUSION

The rate of conversion to OC was 3.7%. Factors such as male gender, history of jaundice due to gallbladder stones, history of pancreatitis, thick gallbladder wall, high white blood cell count, difficulty in handling the gallbladder, and dense adhesions with surrounding tissues were significantly associated with conversion to OC.

Preoperative Waiting Time Affects the Length of Stay of Patients Treated via Laparoscopic Cholecystectomy in an Acute Care Surgical Setting

Background/Objectives: Acute cholecystitis (AC) presents a significant burden in emergency surgical settings. Early laparoscopic cholecystectomy (ELC) is the standard of care for AC, yet its implementation varies. This study aims to assess the impact of preoperative waiting time (WT) on postoperative length of stay (LOS) in patients undergoing urgent cholecystectomy. Methods: From June 2021 to September 2022, data on patients undergoing urgent cholecystectomy for AC or pancreatitis were collected from two university hospitals. Patients were categorized into early (ELC) or delayed (DLC) cholecystectomy groups based on WT. The primary outcome was the assessment of the variables influencing LOS via univariate and multivariate analyses. Results: This study included 170 patients, predominantly female, with a median age of 64.50 years. ELC was performed in 58.2% of cases, with a median WT of 0 days, while DLC was performed in 41.8%, with a median WT of 3 days. Postoperative complications occurred in 21.8% of cases, with LOS being significantly shorter in the ELC group (median 5 days vs. 9 days; p = 0.001). Multivariate analysis confirmed that WT (OR 8.08 (1.65-77.18; p = 0.033)) was the most important predictor of LOS. Conclusions: ELC is associated with a shorter LOS and with DLC, aligning with the WSES recommendations. Earlier surgery reduces the risk of complications and overall hospital costs. An extended WT contributes to a prolonged LOS, underscoring the importance of timely access to operating theaters for acute biliary pathologies.

A Study of Factors Leading to Difficult Laparoscopic Cholecystectomy at a Tertiary Care Center in Northeastern India

BACKGROUND

Laparoscopic cholecystectomy (LC) is currently the gold standard of care for managing gallstone disease. The time taken to perform LC depends on both patient-related and surgeon-related factors. Recognizing factors associated with difficult LC (DLC) can aid in appropriate surgeon selection and judicious scheduling of cases.

METHODS

This prospective study was conducted to identify preoperative factors (clinical and ultrasonographic) and intraoperative factors that can help predict or prepare for DLC. The study took place in the Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India. A total of 100 cases of LC were enrolled over a two-year period. All patients had symptomatic cholelithiasis and were scheduled to undergo elective LC. The time taken to perform LC was compared against individual parameters of interest, including clinical features, ultrasonography (USG), and intraoperative findings.

RESULTS

Forty-one LCs were classified as difficult and 59 as non-DLC (NDLC), based on the time limit set by the mean operating time for all LC cases. Seven out of the 41 difficult LCs required conversion to open cholecystectomy (OC). Patient, USG, and intraoperative factors were found to have a significant correlation with difficult LC. Patient factors included male gender, body mass index (BMI), number of past attacks, and previous abdominal surgery. USG factors included calculi number, calculi size, impaction of calculi, and a thick gallbladder (GB) wall. Intraoperative factors included pericholecystic adhesions, Calot's triangle dissection, GB mobilization from the liver bed, and GB specimen extraction.

CONCLUSION

Preoperative identification of difficult LC cases can guide rational allocation of cases based on surgeon experience, leading to better utilization of operating theatre time and reducing the probability of conversion and complications.

Preoperative predictors of difficult early laparoscopic cholecystectomy among patients with acute calculous cholecystitis in Egypt

BACKGROUND

Early laparoscopic cholecystectomy (ELC) in the setting of acute calculous cholecystitis (ACC) requires to be performed by highly-skilled surgeons to avoid complications. The purpose of this study is to identify preoperative factors that would predict difficult ELC among patients with ACC prior to proceeding with surgery.

METHODS

We retrospectively reviewed all patients who received ELC within 10 days from the onset of symptoms of ACC between August 1, 2018, and December 31, 2022. They were divided into 2 groups according to the difficulty of surgery.

RESULTS

149 patients with ACC received ELC during the study period. ELC was considered difficult in 52 patients (35%). Five preoperative factors were identified as significant predictors of difficult ELC (DELC) on multivariate analysis: duration of acute attack ≥ 4 days from the onset of symptoms till surgery (OR 34.4, P < 0.001), ultrasound showing largest gallstone size > 20 mm (OR 20.2, P = 0.029), ultrasound showing gallstone impaction in Hartmann's pouch (OR 7.2, P = 0.017), history of prior episode(s) of acute attack (OR 6.8, P = 0.048), and diabetes mellitus (OR 5.8, P = 0.046).

CONCLUSION

Careful preoperative assessment of patients with ACC is crucial among junior surgeons with limited surgical expertise prior to proceeding with ELC to identify those at risk of DELC to potentially reduce postoperative morbidity and mortality. If encountered, a management plan should be made, and surgery should proceed only upon confirming the availability of experienced surgeons in the field of biliary and laparoscopic surgery to supervise or assist in the procedure. Alternatively, such group of patients should rather be transferred to more advanced surgical centers which offer higher level of care to maintain patient safety and optimal surgical outcomes. More importantly, bail-out procedures should always be resorted to whenever DELC is encountered intraoperatively to prevent further surgical damage.

Bailout for the Difficult Gallbladder: Subtotal vs. Open Cholecystectomy-A Retrospective Tertiary Care Center Experience

Background and Objectives: A difficult gallbladder anatomy augments the risk of bile duct injuries (BDIs) and other complications during a laparoscopic cholecystectomy. This study compares the outcomes of a laparoscopic subtotal cholecystectomy (LSTC) and open total cholecystectomy (OTC) for difficult cholecystectomies. Materials and Methods: This retrospective analysis of gallbladder procedures (LSTC or OTC) from 2016 to 2023 examined patient demographics, surgical details, and postoperative results. The primary outcome was the incidence of a BDI. Secondary outcomes included operative duration, blood loss, and postoperative complications. Results: Seventy-one patients were included in the study. Of them, 59.2% (n = 42) underwent an LSTC and 44.6% (n = 29) underwent an OTC. The LSTC cohort was more likely to have a day-surgery case with a same-day discharge (33.3% vs. 0%, p = 0.009), less blood loss (71.4 ± 82.26 vs. 184.8 ± 234.86, p = 0.009), and a shorter operative duration (187.86 ± 68.74 vs. 258.62 ± 134.52 min, p = 0.008). Furthermore, BDI was significantly lower in the LSTC group (2.4% vs. 17.2%, p = 0.045). However, there were no significant differences between the two groups concerning intraoperative drain placement, peri-cholecystic fluid collection, bile leak, and other complications (p > 0.05). Conclusions: LSTC is a safe and effective alternative to OTC for challenging gallbladder cases. Further studies with larger sample sizes and longer follow-up periods as well as different study designs are warranted.

Can Hemogram Parameters and Derived Ratios Predict Conversion From Laparoscopic to Open Cholecystectomy?

Backgrounds Laparoscopic cholecystectomy (LC) is the gold standard for surgical removal of gallbladder today. In challenging cholecystectomy cases, conversion to an open technique may be necessary. Therefore, the preoperative prediction of conversion to open technique holds significant importance for patient safety and surgical strategy. In the literature, conversion to open cholecystectomy has been associated with many contradictory predictive factors. The aim of this study is to identify and comprehensively evaluate the predictive laboratory parameters and ratios associated with the conversion from laparoscopic to open cholecystectomy. Methods In this historical cohort study, the data of patients who were scheduled for and underwent LC between January 1, 2018, and September 1, 2023, were retrospectively evaluated. The preoperative laboratory findings and surgical notes of the patients were reviewed retrospectively from the archives. The correlation between patient data and the cholecystectomy groups was analyzed, and comparisons were made between the groups. Results All 160 patients initially underwent a laparoscopic approach. In emergency cases, a statistically significant association was found between lymphocyte count (p = 0.017) and lymphocyte-to-monocyte ratio (LMR) (p = 0.041) with operations completed laparoscopically and between neutrophil-to-lymphocyte ratio (NLR) (p = 0.007) and Systemic Inflammatory Response Index (SIRI) (p = 0.031) with operations converted to open surgery. In elective cases, gamma-glutamyl transferase (GGT) (p = 0.024) and total bilirubin (TBIL) (p = 0.003) were found to have a statistically significant association with operations converted to open surgery. In the logistic regression analysis, hematological parameters and ratios were not found to have a statistically significant relationship in predicting the conversion to open surgery. Conclusion Although significant differences were observed in laboratory parameters and derived ratios such as the NLR and LMR, logistic regression analysis did not identify any of these measures as significant predictors of conversion from laparoscopic to open surgery. Further prospective studies with larger sample sizes are needed in this area.

Beyond the Expected: Evaluating Preoperative Predictors of a Difficult Cholecystectomy Aboard the USNS Comfort

Mini abstract Typical preoperative markers of a difficult laparoscopic cholecystectomy did not apply during the US Naval ShipComfort Deployment in 2019. This prospective study reveals the importance of preparedness for short-term surgical missions, the impact of health care disparities on the severity of disease, and the need for deliberate and thoughtful engagement with host-nation partners.

Laparoscopic subtotal cholecystectomy outcomes across a low-and middle-income country metropolitan health service

BACKGROUND

Laparoscopic subtotal cholecystectomy (LSC) is a safe alternative for difficult cholecystectomies to prevent bile duct injury and open conversion. The primary aim was to detail the use and outcomes on LSCs.

METHODS

Retrospective analysis of a prospectively maintained database of laparoscopic cholecystectomy (LC). Relative clinical factors, outcomes, and 30-day follow-up between LSC and LC were compared using univariate and multivariate analyses.

RESULTS

Six hundred and twenty four cholecystectomies were performed and 53 (8.5%) required LSC. 81.8% were fenestrating LSC. Male sex was significantly overrepresented in the LSC group (p < 0.01) and patients requiring LSC were significantly older (p < 0.01). Same admission cholecystectomy was associated with a higher risk of LSC (p < 0.01). Patients with a history of previous surgery, preoperative ERCP, or percutaneous cholecystostomy had an increased risk of undergoing LSC (p < 0.01). A necrotic gallbladder was the most significant predictor of the need for a LSC (p < 0.001). A contracted gallbladder, extensive adhesions, gallbladder empyema, and severe inflammation were significant predictors of difficulty (all p < 0.01). Postoperative complications occurred in 26.4% of LSC patients. There were ten (18.9%) Clavien-Dindo Grade III complications, 5.7% required ERCPs, and 9.4% required relook laparotomies. Significantly, more patients in the LSC group developed bile leaks (n = 8, 15%) (p < 0.001). There were two readmissions within 30 days, one mortality, and no BDIs occurred in the LSC cohort.

CONCLUSION

LSC provides a feasible surgical option that should be utilized in complex cholecystitis.

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

Introduction

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).

Case series

The authors here report three cases of pucker sign that were incidentally discovered during laparoscopy.

Discussion

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.

Conclusion

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.

Laparoscopic common bile duct exploration: what factors determine success?

BACKGROUNDS

Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP-related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE.

METHODS

All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre-operative investigations, intra-operative findings, technique of bile duct clearance and clearance rates, and post-operative outcomes. Predictors of failed LCBDE were identified.

RESULTS

Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26-0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06-0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected.

CONCLUSION

LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success.

Evaluating Clinical Outcomes of Laparoscopic Subtotal and Total Cholecystectomy for Complicated Acute Cholecystitis: A Systematic Review and Meta-Analysis

INTRODUCTION

This systematic review and meta-analysis aimed to compare clinical outcomes in patients with complicated acute cholecystitis undergoing laparoscopic total vs subtotal cholecystectomy.

METHODS

This systematic review and meta-analysis was conducted according to PRISMA guidelines and queried PubMed, Embase, ProQuest, Google Scholar, and Cochrane databases from inception to May 2023. The primary outcome was complication rates including common bile duct injury, wound infection, reoperation, bile leak, retained stones, and subhepatic collection, whereas secondary outcomes were in-hospital mortality and hospital length of stay.

RESULTS

A total of 7 studies with 135,233 cases were included for meta-analysis. Patients who underwent laparoscopic total cholecystectomy had a significantly lower risk of postoperative bile leaks (RR: .15; 95% CI: .03, .80) and subhepatic fluid collection (RR: 0.19; 95% CI: .06, .63) and were 2.94 times less likely to die compared to those who underwent subtotal cholecystectomy (RR .34; 95% CI: .15, .77). Patients who underwent subtotal cholecystectomy had significantly longer hospital length of stay (mean difference 1.0 days; 95% CI: .5 days, 1.4 days).

CONCLUSIONS

In adult patients presenting with complicated cholecystitis, management with laparoscopic subtotal cholecystectomy presents a unique complication profile with increased risk of postoperative bile leak and subhepatic fluid collection, in-hospital mortality, and longer hospital length-of-stay when used as an alternative approach to laparoscopic total cholecystectomy. Further research into the most appropriate clinical scenarios and patient populations for the use of the subtotal cholecystectomy approach may prove useful in improving its associated outcomes.

Predictive Factors for Difficult Laparoscopic Cholecystectomies in Acute Cholecystitis

Laparoscopic cholecystectomy (LC) is the gold standard treatment in acute cholecystitis. However, one in six cases is expected to be difficult due to intense inflammation and suspected adherence to and involvement of adjacent important structures, which may predispose patients to higher risk of vascular and biliary injuries. In this study, we aimed to identify the preoperative parameters with predictive value for surgical difficulties. A retrospective study of 255 patients with acute cholecystitis admitted in emergency was performed between 2019 and 2023. Patients in the difficult laparoscopic cholecystectomy (DLC) group experienced more complications compared to the normal LC group (33.3% vs. 15.3%, p < 0.001). Age (p = 0.009), male sex (p = 0.03), diabetes (p = 0.02), delayed presentation (p = 0.03), fever (p = 0.004), and a positive Murphy sign (p = 0.007) were more frequently encountered in the DLC group. Total leukocytes, neutrophils, and the neutrophil-to-lymphocyte ratio (NLR) were significantly higher in the DLC group (p < 0.001, p = 0.001, p = 0.001 respectively). The Tongyoo score (AUC ROC of 0.856) and a multivariate model based on serum fibrinogen, thickness of the gallbladder wall, and transverse diameter of the gallbladder (AUC ROC of 0.802) showed a superior predictive power when compared to independent parameters. The predictive factors for DLC should be assessed preoperatively to optimize the therapeutic decision.

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

INTRODUCTION

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 60 minutes 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.

METHODS

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.

RESULTS

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 11 mg/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 11 mg/dL did not face any difficulty during their cholecystectomy. Similar results have been acquired across all age groups and both genders.

CONCLUSION

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 >11 mg/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.

A multifactorial evaluation of objective performance indicators and video analysis in the context of case complexity and clinical outcomes in robotic-assisted cholecystectomy

BACKGROUND

The increased digitization in robotic surgical procedures today enables surgeons to quantify their movements through data captured directly from the robotic system. These calculations, called objective performance indicators (OPIs), offer unprecedented detail into surgical performance. In this study, we link case- and surgical step-specific OPIs to case complexity, surgical experience and console utilization, and post-operative clinical complications across 87 robotic cholecystectomy (RC) cases.

METHODS

Videos of RCs performed by a principal surgeon with and without fellows were segmented into eight surgical steps and linked to patients' clinical data. Data for OPI calculations were extracted from an Intuitive Data Recorder and the da Vinci ® robotic system. RC cases were each assigned a Nassar and Parkland Grading score and categorized as standard or complex. OPIs were compared across complexity groups, console attributions, and post-surgical complication severities to determine objective relationships across variables.

RESULTS

Across cases, differences in camera control and head positioning metrics of the principal surgeon were observed when comparing standard and complex cases. Further, OPI differences across the principal surgeon and the fellow(s) were observed in standard cases and include differences in arm swapping, camera control, and clutching behaviors. Monopolar coagulation energy usage differences were also observed. Select surgical step duration differences were observed across complexities and console attributions, and additional surgical task analyses determine the adhesion removal and liver bed hemostasis steps to be the most impactful steps for case complexity and post-surgical complications, respectively.

CONCLUSION

This is the first study to establish the association between OPIs, case complexities, and clinical complications in RC. We identified OPI differences in intra-operative behaviors and post-surgical complications dependent on surgeon expertise and case complexity, opening the door for more standardized assessments of teaching cases, surgical behaviors and case complexities.

Can gallbladder wall thickness and systemic inflammatory index values predict the possibility of conversion from laparoscopy to open surgery?

Background/Objective

This study aims to develop an objective marker that predicts the risk of conversion from laparoscopy to open surgery using gallbladder wall thickness and inflammatory index values.

Materials and Methods

A total of 2,920 cholecystectomy patients were screened, including those whose operations were converted to open and those who underwent laparoscopy. A total of 700 cholecystectomy patients who met the study criteria were included in the study. The same team of surgeons performed all operations. The conversion probability from laparoscopic to open cholecystectomy was calculated using the ratio obtained by evaluating inflammatory markers and gallbladder wall thickness (K). The preoperative complete blood count and abdominal ultrasound data of the patients were obtained from our university patient registry system.

Results

Age, neutrophil count, gallbladder wall thickness, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), KxNLR, and KxPLR values were all significantly higher in the conversion from laparoscopy to open surgery group compared with the laparoscopic cholecystectomy group. According to the ROC analysis performed on the gallbladder wall thickness values according to the probability of conversion to open surgery, the cutoff value was determined as >3 mm. Gallbladder wall thickness >KxPLR >KxNLR was defined as the diagnostic value order according to the area under the curve.

Conclusions

The results of this study showed that gallbladder wall thickness effectively determines the probability of conversion from laparoscopy to open cholecystectomy and multiplying the gallbladder wall thickness (mm) by NLR increased the sensitivity.

Comparison between peripheral nerve stimulator-guided serratus anterior plane block versus transversus abdominis plane block for postoperative analgesia in laparoscopic cholecystectomy under general anaesthesia: A double-blind randomised controlled trial

Background and Aims

Laparoscopic cholecystectomy (LC) is a widely accepted surgical procedure associated with postoperative pain. This study was done to compare peripheral nerve stimulator (PNS)-guided serratus anterior plane block (SAP) and transversus abdominis plane (TAP) block for postoperative analgesia for patients undergoing LC.

Methods

Following approval from the ethical committee, 70 patients for LC were randomly assigned to Group S: SAP block and Group T: TAP block. The blocks were performed under PNS guidance, and 20 ml of 0.375% ropivacaine was administered. The severity of pain was measured using a visual analogue scale (VAS). The study's primary objective was the evaluation of the postoperative VAS score. The time of the first dose of rescue analgesia and total tramadol consumption for 24 h postoperatively were secondary objectives. All the statistical calculation was done using statistical analyses for Social Sciences for Windows version 23.0 (IBM Corp, NY, USA).

Results

Lower VAS score was seen in patients of TAP block at rest as well as movement at 6 h (P = 0.001), 12 h (P = 0.001) and 18 h (P = 0.001) postoperatively compared with SAP. The TAP group showed a significantly increased time of first rescue analgesic compared to the SAP group (7.97 ± 0.51 vs. 5.89 ± 1.45, P = 0.001). Tramadol usage was significantly higher in the SAP group than in the TAP group (128.9 ± 36.22 vs. 72.43 ± 44.80, P = 0.001).

Conclusion

TAP block guided by the PNS improves postoperative pain with less tramadol consumption and during the postoperative period without significant complications.

Defining Critical View of Safety During Laparoscopic Cholecystectomy: The Preoperative Predictors of Failure

Background Defining critical view of safety (CVS) is one of the most crucial steps during laparoscopic cholecystectomy (LC). This study aimed to determine the preoperative predictors of failure to achieve CVS during LC. Methods All patients undergoing LC from December 2020 to July 2022 were prospectively included. Results There were 180 females and 93 males. CVS was achieved during LC in 238 (87.2%) patients. Conversion to open surgery was performed for 11 patients. Bile leak occurred in three patients which resolved spontaneously. No patient developed bile duct injury. On univariate analysis, age, male sex, American Society of Anaesthesiologists (ASA) grading, Murphy's sign, emergency surgery, neutrophil percentage, lymphocyte percentage, gallbladder wall thickness > 3mm, and impacted gallstone on abdominal ultrasound were predictors of failure to achieve CVS. On multivariate analysis, neutrophil and lymphocyte percentages were independent predictors of failure to achieve CVS. Patients in whom CVS could not be achieved had significantly longer operative time, higher blood loss, complications, and hospital stays. Discussion Inability to achieve CVS during LC can be predicted preoperatively using various parameters including neutrophil and lymphocyte percentages. Such cases must be operated by senior surgeons or referred to experienced general or hepatobiliary surgeons for cholecystectomy to avoid bile duct injury. The proposed algorithm can help in intraoperative decision-making in difficult cases.

The Modification of a Preoperative Scoring System to Predict Difficult Elective Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy (LC) is one of the most common abdominal operations. The difficult cases are still challenging for surgeons. There had been many studies providing several preoperative models to predict difficult LC or conversion. Randhawa's scoring system was a simple and practical predictive model for clinicians. The modification was reported to be more preferable for delayed LC. This study aimed to confirm the advantage of modified predictive model in larger sample size. Materials and Methods: This retrospective cohort study reviewed medical records of patients who underwent LC since January 2017 to December 2021. The difficulty of operation was categorized into three groups: easy, difficult, and very difficult. Multivariate analysis was performed to define significant factors of very difficult and converted cases. The predictive scores were calculated by using the original Randhawa's model and the modification, then compared with actual outcome. Results: There were 567 cases of delayed LC in this study, with 44 cases (7.8%) converted to open cholecystectomy. Four factors (previous cholecystitis, previous endoscopic retrograde cholangiopancreatography, higher ALP, and gallbladder wall thickening) for very difficult group and five factors (previous cholecystitis, previous cholangitis, higher white blood cell count, gallbladder wall thickening, and contracted gallbladder) for conversion were significant. The modification provided the better correlation and higher area of receiver operating characteristic (ROC) curve comparing with the original model. Conclusion: The modification of Randhawa's model was supposed to be more preferable for predicting the difficulty in elective LC. Thai Clinical Trials Registry No. 20220712006.