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A Prospective Study of Pre-Operative Predictors of Difficult Laparoscopic Cholecystectomy

BACKGROUND : 
Cholelithiasisis the most common biliary pathology, with a prevalence of 10 to 15%. It is symptomatic in approximately 1to2% of patients. N I H consensus development stated that laparoscopic cholecystectomy “ Provides a Safe and Effective treatment for most patients with symptomatic gallstones”. In about 5 to 10% of laparoscopic cholecystectomy, conversion to open cholecystectomy may be needed for safe removal of gall bladder. 
OBJECTIVES : 
To determine the predictive factors for difficult laparoscopic 
cholecystectomy 
To study the clinical presentation of cholelithiasis 
METHODS : 
The material for the present study comprised of 50 cases admitted to Govt Rajaji hospital Madurai from March 2013 to august 2014 for a period of 18 months. The cases confirmed by Ultrasonography were evaluated with following risk factors: age > 50years, male sex, BMI 25.1 to 27.5 and >27.5, previous surgery, prior hospitalization, palpable gall bladder, gall bladder wall thickening, impacted stone, 
pericholecystic fluid collection. Each risk factor was given a score. The total score upto 5 predicted easy, 6 to 10 difficult and more than 10 very difficult. 
RESULTS : 
The highest age incidence of cholelithiasis was in the 4th decade, and was more common in females. Pain abdomen was the most common symptom. Ultrasonography detected gall bladder stones in all patients, wall thickening in 15 and pericholecystic fluid collection in 10. BMI >27.5 (P<0.001), history of prior hospitalization (P<0.0008), palpable gallbladder (p<0.0364), impacted stone (P<0.0103) and Pericholecystic fluid collection (P<0.0471) were significant predictors of difficult laparoscopic cholecystectomy. 
INTERPRETATION AND CONCLUSION : 
The proposed scoring system had a positive prediction value for easy prediction of 94.7% and for difficult prediction of 100%.The conversion rate from laparoscopic cholecystectomy to open cholecystectomy was 10%.