ASSESSMENT OF THE RANDHAWA AND PUJAHARI PREOPERATIVE SCORING SYSTEM FOR LAPAROSCOPIC CHOLECYSTECTOMY DIFFICULTLY

The risk factors for conversion are: more than 65 years old, male gender, previous upper abdominal surgery, and history of acute cholecystitis ⁽⁶⁾. Ultrasonography is the most frequent investigation for cholecystitis and cholelithiasis and can help to predict intraoperative difficulty.

Here we assess how well a preoperative scoring system for difficult laparoscopic cholecystectomy predicts intraoperative difficulty.

Methods

This prospective investigation enrolled 133 patients of both genders, aged 41–67 years, with cholelithiasis and scheduled for elective laparoscopic cholecystectomy at King Talal military hospital, Mafraq,and Prince Rashid hospital, Jordan, during the years 2018–2019. Written informed consent was obtained from all patients and approval from our local ethical and research board review committee of the Royal medical services. Patients with acute cholecystitis, empyema of GB, CBD stones, and cholangitis were ruled out.

The preoperative anticipative factors of difficult laparoscopic cholecystectomy (scoring system of Randhawa and Pujahari⁽⁷⁾ ) are: (I) age, gender, and previous admission for acute cholecystitis; (II) BMI, abdominal scar, and palpable gallbladder; and (III) ultrasound findings, such as wall thickness of gallbladder, pericholecystic collection, and impacted stone (Table 1). Intraoperative findings were evaluated for grading of difficult laparoscopic cholecystectomy (scoring system of Randhawa and Pujahari) ⁽⁷⁾ (Table 1). The preoperative scores were compared with intraoperative scores as predictors. The laparoscopic cholecystectomy difficulty was graded in terms of the preoperative score as: easy (0–5), difficult (6–10), and very difficult (11–15), with a maximum score of 15. The intraoperative scoring system (easy, difficult, very difficult surgery) considers surgery time, bile/stone spillage, insult to a duct, and conversion to open cholecystectomy.

Statistics
Univariate and multivariate logistic regression analyses were performed to anticipate difficulty. Multivariate analysis of logistic regression was used to find the predictive factors for predicting preoperative outcome namely easy and difficult in which three categories of difficulty were clustered in. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Most patients were females [n = 110 (82.7%)] with a female to male ratio of 4.8:1, and the median age was 51 years (range: 41–67 years) (Table 2). In terms of ultrasound findings, 100 patients (75.2%) had multiple calculi, while 33 patients (24.8%) had solitary stone; 40 patients (30.1%) had impacted stone, 28 patients (21.1%) had wall thickening more than or equal to 4 mm, and a pericholecystic collection was recorded in 25 patients (18.8%) (Table 2). The association between the anticipation of difficulty before surgery and the outcome is demonstrated in Table 3.On preoperative assessment, 39 (29.3%) patients were classified as difficult/very difficult, of whom 35 (89.7%) patients had a difficult/very difficult surgery, and four (10.3%) an easy surgery. Most (94, 70.7%) patients were classified as easy on preoperative assessment, of whom 84 (89.4%) patients had an easy surgery, and ten (10.6%) had a difficult/very difficult surgery (Table 3). Eleven (28.2%) patients were converted to open cholecystectomy from 39 patients anticipated difficult/very difficult on preoperative assessment. Eight (8.5%) patients were

converted to open from 94 patients anticipated easy on preoperative assessment. There were 19 (14.3%) conversions, of which 12 were males, and seven patients were females. The cause of conversion was: dense adhesions at Calot's triangle (13 patients), Mirrizi's syndrome (three patients), and uncontrolled bleeding (three patients).

In the univariate and multivariate analyses of the outcome before surgery with risk factors, the previous admission for acute cholecystitis and wall thickness were statistically significant predictors for difficult laparoscopic cholecystectomy. In the univariate analysis, age, BMI more than 30, palpable gallbladder, and impacted stone were predictors of difficult laparoscopic cholecystectomy (Table 4). In terms of univariate and multivariate analyses of outcome during surgery with risk factors, previous admission and wall thickness were predictors of difficult laparoscopic cholecystectomy. In the univariate analysis, age, gender, palpable gallbladder, and impacted stone were statistically significant predictors for difficult laparoscopic cholecystectomy (Table 5). There was an association (P < 0.0045(OR=11.12)) between the preoperative score and the intraoperative score of laparoscopic cholecystectomy patients; patients with an easy preoperative score mainly have an easy intraoperative score.

DISCUSSION

Laparoscopic cholecystectomy can be complicated by dense adhesions in Calot's triangle, empyema of the gallbladder, Mirrizi's syndrome, and acute cholecystitis ⁽⁸⁾. Age above 50 years has also been identified as a significant risk factor for difficult laparoscopic cholecystectomy ⁽⁹⁾. In our investigation, by univariate analysis regarding preoperative and intraoperative findings, there was a remarkable association between age above 50 years and difficult operation. Male gender was correlated with difficult laparoscopic cholecystectomy ⁽¹⁰⁾. A high conversion frequency has been recorded in males ⁽²⁾. In our investigation, 12 of 23 (52.2%) male patients were converted to open surgery. By univariate analysis of intraoperative findings, there was a remarkable association between male gender and operative difficulty.

Patients with repeated admissions for acute cholecystitis have more frequency of difficult laparoscopic cholecystectomy and conversion because of dense adhesions at Calot's triangle and GB fossa ⁽²⁾. In our investigation, admission was remarkably recorded as a predictor for difficult laparoscopic cholecystectomy in both univariate and multivariate analyses in preoperative and intraoperative findings. Laparoscopic surgery is difficult in obese patients as port insertion requires greater time, and dissection at the Calot's triangle is difficult ⁽¹¹⁾. In our investigation, BMI more than 30 was a predictor of difficult laparoscopic cholecystectomy, but only by univariate analysis of the preoperative findings. Supra and infraumbilical scars can lead to adhesions, risking insult to any structures and associated with increased conversion ⁽²⁾. In our investigation, the abdominal scar was insignificant in both univariate and multivariate analyses of preoperative and intraoperative findings. A palpable gallbladder is caused by a distended gallbladder, mucocele of the gallbladder, and adhesions. In univariate analysis of preoperative and intraoperative findings, a palpable gallbladder was identified as a significant predictor.

Increased thickness of the gallbladder wall is correlated with difficult dissection at the bed and at Calot's triangle. In our investigation, there was a remarkable correlation between the gallbladder wall thickness and the operative difficulty in univariate and multivariate analyses of preoperative and intraoperative findings. The pericholecystic collection was a predictor of difficult laparoscopic cholecystectomy ⁽¹²⁾, while it was insignificant in other trials ⁽⁷⁾. In our investigation, there was no correlation between pericholecystic collection and the operative difficulty in univariate and multivariate analyses of preoperative and intraoperative findings. Impacted stone at the neck of the gallbladder can be problematic in laparoscopic cholecystectomy. In our investigation, the impacted stone at the neck of the gallbladder was remarkable in univariate analysis of preoperative and intraoperative findings.

Conversion frequency was recorded in other studies as 7–35% ⁽²⁾ or 25% in difficult patients ⁽¹³⁾. The preoperative scoring system is a good test for anticipating the operative result in laparoscopic cholecystectomy ⁽²⁾. Laparoscopic surgical intervention for cholecystectomy is the optimum technique for symptomatic gallbladder stone disease management as minimal invasiveness operation with minimal pain, early emergence, with less insult of access and no obscuring of the surgical field ⁽¹⁴⁾.

Conclusion

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