{'fraction_non_alphanumeric': 0.030478714593341064, 'fraction_numerical': 0.02252774556899122, 'mean_word_length': 5.086693548387097, 'pattern_counts': {'":': 0, '<': 1, '<?xml version=': 0, '>': 2, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Validation of the Dash, Bhondave, and Gadekar Score System to Predict the Difficulties of Laparoscopic Cholecystectomy

Background: One of the treatment options for cholelithiasis is laparoscopic cholelithiasis. The challenge of this procedure is to determine the level of surgery. Methods: This analytic cross-sectional study was conducted at Sanglah Hospital Denpasar from January 2019 to September 2020. Several risk factors data were assessed according to the Risk Scoring System for Laparoscopic Cholecystectomy. Receiver Operating Characteristic (ROC) curve was plotted to determine the cut-off score based on the most optimal sensitivity and specificity to predict the difficulty of surgery. Univariate statistical analysis was conducted based on the type of data with a p-value <0.05 considered significant. Results: From a total of 62 laparoscopic cholecystectomies, 36 (58.1%) case was a simple surgery, and 26 (41.9%) was difficult surgery. In the difficult surgical group, 17 surgeries (27.4%) were more than 60 minutes, nine surgeries (14.5%) with bile spillage, and one surgery (1.6%) with ductal injury. The scoring system had a sensitivity of 86.1%, a specificity of 76.9%, a positive predictive value of 83.7%, and a negative predictive value of 80%. Conclusion: A scoring system is a promising approach to estimating the difficulty of laparoscopic cholecystectomy. Further study to improve this scoring system is necessary.


Introduction
One of the most common problems affecting the digestive tract is gallstone disease. Along with the increasing socio-economic conditions of the community, changes in food patterns, and improvements in diagnostic facilities, the prevalence of gallstone disease in developing countries tends to increase. [1][2][3] The incidence of cholelithiasis is 8% in men aged over 40 years and 40% in women over 65 years. 4,5 Most cases require surgery as therapy with laparoscopic cholecystectomy as the preferred method. 6 In several cases, laparoscopic cholecystectomy can be difficult and requires more aggressive measures. It is estimated that around 1-13% of laparoscopic cholecystectomy converted to open cholecystectomy due to various causes. The risk factors associated with this incidence vary, including surgeon factors, equipment failure, and patient factors such as age, gender, or body mass index (BMI). 7 Other factors related include a history of upper abdominal surgery, the incidence of acute cholecystitis, gallbladder wall thickness, increased body temperature, and diabetes. 8 The degree of difficulty is challenging to determine for every patient. Nevertheless, it is essential to prepare the surgical process and explain to the patient the procedure to be carried out. Therefore, it would be very beneficial if there were specific criteria that could assess operative risk. 3,5,6,[9][10][11][12][13][14][15][16] Several assessment methods have been proposed with various criteria but are still controversial. Considering the risks of surgery and the purpose of obtaining the benefits of surgery for both the patient and the medical team, the authors consider it necessary to raise the topic of a scoring system to predict the difficulty level of laparoscopic cholecystectomy surgery.

Methods
This study is a cross-sectional analytic study that Scoring System for Laparoscopic Cholecystectomy.
The scoring system used in this study was adapted from the scoring system published by Bhondave et al. 3 The scores for each variable are summarized in Table   1. The assessment was divided into two categories, namely simple and difficult. The classification system was adapted from the criteria used by Bhondave et al. 7 In this study, we decided that if one of the criteria for laparoscopic cholecystectomy was difficult to fulfill, then the operation was declared difficult. The criteria for each category are summarized in Table 2. Table 2. The assessment of the difficulty level of laparoscopic cholecystectomy

Parameter Classification
These three criteria must be met: Simple Duration of surgery ≤ 60 minutes

Results
This study involved 62 respondents in determining  Table 3. To determine the ability of laparoscopic cholecystectomy scoring to predict the difficulty of surgery, we use the ROC curve ( Figure 1 and Table 4). with a value of 9.5. The best cut-off point results were analysed using a 2x2 table presented in Table 5.

Discussion
Laparoscopic cholecystectomy has become the gold standard in treating symptomatic cholelithiasis. Thus risk reduction is a crucial aspect of surgery planning.
Predictions before surgery propose to avoid unnecessary time prolongation and to prevent complications. 17  showed the total number of leukocytes to be a significant predictor. Bhondave et al. 3 found that a thickness ≤4 mm was only 67.4% compared to a thickness >4 mm, and a gallbladder wall thickening >4 mm was associated with the difficulty of laparoscopic cholecystectomy (p = 0.000005). Similar results were obtained in this study and supported by Gupta et al. 16 but differed in the study of Agarwal et al. 19 , which did not find a significant relationship between them.
Our study showed a significant association between the presence of fluid accumulation and surgical difficulty following other studies that have been reported. 3,17,19 Impacted gallstones were found to have an association, but different results were reported in another study. 3 There was no change in hepatic echotexture in this study. This study showed that the sensitivity of the scoring system was 86.1% and a specificity of 76.9%.
The positive predictive value is 83.7%, while the negative predictive value is 80%. These results are expected to prevent risks during surgery and guide health practitioners in predicting the difficulty level of pre-operative laparoscopic cholecystectomy using a scoring system.

Conclusion
A scoring system is a promising approach to estimating the difficulty of laparoscopic cholecystectomy. Further study to improve this scoring system is necessary.