A Study of Factors Leading to Difficult Laparoscopic Cholecystectomy at a Tertiary Care Center in Northeastern India

Background: Laparoscopic cholecystectomy (LC) is currently the gold standard of care for managing gallstone disease. The time taken to perform LC depends on both patient-related and surgeon-related factors. Recognizing factors associated with difficult LC (DLC) can aid in appropriate surgeon selection and judicious scheduling of cases.

Methods: This prospective study was conducted to identify preoperative factors (clinical and ultrasonographic) and intraoperative factors that can help predict or prepare for DLC. The study took place in the Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India. A total of 100 cases of LC were enrolled over a two-year period. All patients had symptomatic cholelithiasis and were scheduled to undergo elective LC. The time taken to perform LC was compared against individual parameters of interest, including clinical features, ultrasonography (USG), and intraoperative findings.

Results: Forty-one LCs were classified as difficult and 59 as non-DLC (NDLC), based on the time limit set by the mean operating time for all LC cases. Seven out of the 41 difficult LCs required conversion to open cholecystectomy (OC). Patient, USG, and intraoperative factors were found to have a significant correlation with difficult LC. Patient factors included male gender, body mass index (BMI), number of past attacks, and previous abdominal surgery. USG factors included calculi number, calculi size, impaction of calculi, and a thick gallbladder (GB) wall. Intraoperative factors included pericholecystic adhesions, Calot's triangle dissection, GB mobilization from the liver bed, and GB specimen extraction.

Conclusion: Preoperative identification of difficult LC cases can guide rational allocation of cases based on surgeon experience, leading to better utilization of operating theatre time and reducing the probability of conversion and complications.