La cholervm

1. “ Pre-operative prediction of difficult laparoscopic
cholecystectomy using clinical and
ultrasonographic parameters”
Department of Surgery
G.R. MEDICAL COLLEGE, GWALIOR
Presented by :
Dr. Deepti Chaturvedi
Pg resident
GUIDE:
Dr M.M. MUDGAL
MS FIAGES
Professor
Department of surgery
G.R.M.C
CO-GUIDE:
Dr. Rakesh DARBAR
MS FMAS
Assistant professor
Department of surgery
G.R.M.C
Department of Surgical Gastroenterology, Seth G S Medical
College and K E M Hospital, Mumbai.

2. Objective
• To evaluate the clinical and ultrasonographical
factors predicting difficult laproscopic cholecystec
tomy preoperatively.

3. Introduction
The laparoscopic procedure was first described in 1989 and since th
en the clinical and economical benefits have been proven in te
rms of comparable or even shorter opeating time, shorter hospital
stay and more rapid return to full activity.
When significnt difficulties or complictions arise in a laproscopic pr
ocedure, conversion to an open procedure should be considered.

4. Material & methods
• A prospective observational study
• Eligible Patients- 105
• Duration of study- May 2017 to January 2019
• Patient characteristics,clinical history, laboratoy
data, ultrasonographic details and intraoperative
findings were analysed to determine predictors o
f difficulty.

5. Inclusion criteria
All patients with symptomatic Cholelithiasis, Normal
LFT and Nondilated Bile ducts.
Exclusion criteria
•Exclusion Crieteria- Multiple Common bile duct stone,
suspected malignacy.

6. Definition of Variables
• Pre-operative Variables
1. Age: Evaluated as a dichotomous variabl (<65yr or >65 yrs ) as
well as continuous variable.
2. Body Mass Index: Dichotomous variable (<30Kg/m2)
3. Previous abdominal surgery : none vs any intra-abdominal
surgery.
4. Subcostal angle: narrow or wide (>90°)

7. 5. USG parameters
•Gallbladder: contracted or distended (>5cms) depending on the s
hape and transverse diameter.
•GB wall thickness: max obtainable measurement.
•Calculus size: <1cm vs >1cm
•No of calculi: solitary vs multiple

8. • Dependent Variables (Outcome)
1. Duration of surgery ( in minutes: time from insertion of veress
needle to closure of trocar insertion site)
2. Bleeding during surgery( minimal, moderate: tachycardia
without drop in BP) or severe (tachycardia with drop in BP)
3. Access to peritoneal cavity(easy or difficult: subjective to
operating surgeon)
4. GB bed dissection

9. 5. Difficult extraction
6. Extension of incision for extraction
7. Conversion to open cholecystectomy

10. Statistical Analysis
• SAS software was used fo stastistical analysis.
• First, chi square test was used to determine factors that were asso
ciated with difficult LC ( p value <0.05).
• Next, out of these five variables were assigned dichotomous valu
e of either 1 or 0.
• Past H/o surgery, past h/o acute cholecystitis, BMI >30Kg/m2, G
B wall thickness >3mm, male patients.
• These values were put in a formoula that allowed calcultion of pr
obability of conversion to OC in an individual.

11. Results
• Difficulty in access to peritoneal cavity was encountered more
often in 1) Obese patient (p value<0.05) 2) Patients with past
history of abdominal surgery ( <0.01)
• Bleeding occured more often in 1) patients with previous upper
abdominal surgery (< 0.05 p value) 2) GB wall thickness > 3 mm.
3) past history of acute cholecystitis (p value <0.01)
• Difficult dissection of GB bed was seen with past h/o acute
cholecystitis and GB wall thicknes > 3 mm.

12. • Difficulty in extraction was associated with a calculus size > 1
cm.
• Conversion to OC was required due to - 1) inability to delineate
anatomy 2) Bleeding 3) Suspected CBD injury

13. Discussion
• Conversion to OC is required in 2% - 15% of patients
undergoing LC.
• Need for conversion to laparotomy is neither a failure nor a
complication of LC, but an attempt to avoid complictions.
• Determining the risk of conversion helps both the patient and
surgeon prepare better for surgery.
• High predicted risk of conversion may allow the surgeon to take
an early decision to convert to OC.

14. Conclusion
In conclusion, clinical and ultrasonographic findings
may help predict a difficult LC, this informtion may be
useful to both the patients and the treating surgeon.

15. References
1. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The
spread of the obesity epidemic in the United States 1991-1998. JAMA
1999;282:1519-22.
2. Peters JH, Krailadsiri W, Incarbone R, Bremner C, Froes E, Ireland A, et al.
Reasons for conversion from laparoscopic to open cholecystectomy in an urban
teaching hospital. Am J Surg 1994;168:555-9.
3. Daradkeh SS, Suwan Z, Abu-Khalaf M. Preoperative ultra- sonography and
prediction of technical difficulties during laparoscopic cholecystectomy. World J
Surg 1998;22:75-7.
4. Santambrogio R, Montorsi M., Bianci P, Opocher E, Schubert L, Verga M, et al.
Technical difficulties and complications during laparoscopic cholecystectomy:
predictive use of preoperative ultrasonography. World J Surg 1996;20:978- 82.
5. Alponat A, Kum CK, Koh BC, Rajnakova A, Goh PM. Predictive factors for
conversion of laparoscopic cholecys- tectomy. World J Surg 1997;21:629-33.
6. Sanabria JR, Gallinger S, Croxford R, Strasberg SM. Risk factors in elective
laparoscopic cholecystectomy for con- version to open cholecystectomy. J Am Coll
Surg 1994;179:696-704.

16. THANK YOU