This document summarizes a study that aimed to evaluate preoperative clinical and ultrasonographic factors that can predict difficult laparoscopic cholecystectomies. The study prospectively analyzed 105 patients undergoing laparoscopic cholecystectomy between May 2017 and January 2019. Several preoperative variables were analyzed including age, BMI, previous abdominal surgery, gallbladder wall thickness on ultrasound, and number and size of gallstones. The study found that difficulty accessing the peritoneal cavity was associated with obesity and previous abdominal surgery. Bleeding during surgery was associated with previous upper abdominal surgery, thickened gallbladder wall, and history of acute cholecystitis. Difficult gallbladder bed dissection was seen in those with prior cholecystitis

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
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