Predicting difficult laparoscopic cholecystectomy

Atul Kumar Gupta, Nitin Shiwach, Sonisha Gupta, Shalabh Gupta, Apoorv Goel, Tripta S. Bhagat


Background: Laparoscopic cholecystectomy (LC) has become the gold standard treatment for gallstone disease. Though mostly safe occasionally it can be difficult due to various problems faced during surgical procedure. Anticipation of likely difficulty can help in avoiding complications.

Methods: With the aim of identifying various predictors of difficulty and their correlation with likely difficulty this prospective study on 50 adults undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis was undertaken. Various clinical, radiological and biochemical predictors and frequency and type of intraoperative difficulty was recorded.

Results: In present study adverse clinical factors only showed significant predictive value (p value - 0.005). Adverse radiological predictors although showing trend towards, did not achieve statistical significance (p value 0.065). In clinical predictors duration of symptoms >1yr, History of acute cholecystitis and BMI >30 showed statistically significant association. Age >50yrs, Male gender, radiological predictors (Thickened gall bladder wall, small contracted gall bladder, Single large impacted stone) and deranged LFT did not show significant predictive value.

Conclusions: Clinical predictors are most reliable factors. Use of good clinical judgement regarding possibility of and likely difficulty along with understanding of available resources is important in making decision in each case.


Clinical, Difficult laparoscopic cholecystectomy, Predictors, Predicting, Radiological

Full Text:



Tendon R. Diseases of gallbladder and biliary tract. API text book of medicine. Eds. Shah SN, 7th Ed. 2003;642-44.

Das S. Biliary system. In: Das S, editor. A Concise Textbook of Surgery. 6th Ed. S.R. Das Publishers Kolkata; 2010.

Zinner MJ, Ashley SW. Maingot’s Abdominal Operations. China: The McGraw-Hill Companies; 2013.

Alponat A, Kum CK, Koh BC, Rajnakova A, Goh PM. Predictive factors for conversion of laparoscopic cholecystectomy. World J Surg. 1997;21(6):629-33.

Sanabria JR, Gallinger S, Croxford R, Strasberg SM. Risk factors in elective laparoscopic cholecystectomy for conversion to open cholecystectomy. J Am Coll Surg. 1994;179:696-704.

Lee NW, Collins J, Britt R, Britt LD. Evaluation of preoperative risk factors for converting laparoscopic to open cholecystectomy. Am Surg. 2012;78(8):831-3.

Hussain A. Difficult laparoscopic cholecystectomy: current evidence and strategies of management. Surg Laparosc Endosc Percutan Tech. 2011;21(4):211-7.

Simopoulos C, Botaitis S, Polychronidis A, Tripsianis G, Karayiannakis AJ. Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy. Surg Endosc. 2005;19:905-9.

Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, Kapur A, et al. Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg. 2013;11(9):1002-6.

Acharya A, Adhikari SK. Preoperative Scoring System to Predict Difficult Laparoscopic Cholecystectomy. PMJN. 2012;12:(1):46-50.

Nakeeb A, Comuzzie AG, Martin L. Gallstones: Genetics versus environment. Ann Surg. 2002;23:835-42.

Sharma R, Sachan SG, Sharma SR. Preponderance of gallstone in female. Korea. 2013;1(1):12-3.

Ibrahim S, Tay KH, Lim SH. Risk factors for conversion to open surgery in patients undergoing laparoscopic cholecystectomy. World J Surg. 2006;30:1698-704.

Yol S, Kartal A, Vatansev C, Aksoy F, Toy H. Sex as a factor in conversion from laparoscopic cholecystectomy to open surgery. J Society Laparoendos Surgeons. 2006;10:359-63.

Nidoni R, Udachan TV, Sasnur P, Baloorkar R, Sindgikar V, Narasangi B. Predicting difficult laparoscopic cholecystectomy based on clinicoradiological assessment. JCDR. 2015 Dec;9(12):PC09.

Zisman A, Gold-Deutch R, Zisman E, Negri M, Halpern Z, Lin G, et al. Is male gender a risk factor for conversion of laparoscopic into open cholecystectomy? Surg Endosc. 1996;10:89.

Schrenk P, Woisetschlager R. Laparoscopic cholecystectomy. Surg Endosc. 1995;9:25.

Rosen M, Brody F, Ponsky J. Predictive factors for conversion of laparoscopic cholecystectomy. Am J Surg. 2002;184:254-8.

Bhar P, Ray RP, Halder SK, Bhattacharjee PK. Pre-operative Prediction of Difficult Laparoscopic Cholecystectomy. 2013;128-133.

Thyagarajan M, Balaji Singh, Arulappan Thangasamy, Rajasekar S. Risk factors influencing conversion of laparoscopic cholecystectomy to open cholecystectomy Int Surg J. 2017;4(10):3354-7.

Liu CL, Fan ST, Lai EC, Lo CM, Chu KM. Factors affecting conversion of laparoscopic cholecystectomy to open surgery. Arch Surg. 1996;131(1):98-101.

Ashish K. Khetan, Meenakshi Yeola. Preoperative prediction of difficult laparoscopic cholecystectomy using a scoring system. Int Surg J. 2017 Oct;4(10):3388-3391.

Nachnani J, Supe A. Pre-operative prediction of difficult laparoscopic c oscopic c oscopic cholecystectomy using clinical and ultrasonographic parameters.

Kanaan SA, Murayama KM, Merriam LT, Dawes LG, Rege RV, Joehl RJ. Risk Factors for Conversion of Laparoscopic to Open Cholecystectomy. J Surgical Res. 2002;106(1):20-4.

Lipman JM, Claridge JA, Haridas M, Martin MD, Yao DC, Grimes KL, et al. Preoperative findings predict conversion from laparoscopic to open cholecystectomy. Surg. 2007;142:556-65.

Vivek MA, Augustine AJ, Rao R. A comprehensive predictive scoring method for difficult laparoscopic cholecystectomy. J Mini Acc Surg. 2014;10(2):62.

Lal P, Agarwal PN, Malik VK, Chakravarti AL. A difficult laparoscopic cholecystectomy that requires conversion to open procedure can be predicted by preoperative ultrasonography. JSLS. 2002;6(1):59.

Carmody E, Arenson AM, Hanna S. Failed or difficult laparoscopic cholecystectomy: can preoperative ultrasonography identify potential problems? J Clin Ultrasound. 1994;22(6):391-6.

Khandelwal N, Salim M, Gandhi A. Predicting difficult Laparoscopic Cholecystectomy based on clinico radiological parameters.

Randhawa JS, Pujahari AK. Preoperative prediction of difficult lap chole: a scoring method. Indian Journal of Surgery. 2009;71(4):198-201.

Husain A, Pathak S, Firdaus H. Assessment of operative predictors for difficulty in laproscopic cholecystectomy. Inte J Contemporary Med Res. 2016;3(4):1232-4.

Simopoulos C, Polychronidis A, Botaitis S, Perente S, Pitiakoudis M. Laparoscopic cholecystectomy in obese patients. Obes Surg. 2005;15(2):243e6.