|Year : 2020 | Volume
| Issue : 2 | Page : 208-211
Pre-operative scoring method for assessing the easiness of laparoscopic cholecystectomy
Thejas Lal, Alex Oommen, E Manjush
Department of General Surgery, Government Medical College, Kozhikode, Kerala, India
|Date of Submission||08-Aug-2020|
|Date of Decision||13-Aug-2020|
|Date of Acceptance||14-Oct-2020|
|Date of Web Publication||07-Nov-2020|
Dr. Thejas Lal
Siromani Bhavan, Arattuthara P. O., Mananthavady, Wayanad - 670 645, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Laparoscopic cholecystectomy is now the gold standard treatment modality for cholelithiasis. Many pre-operative factors affect the proceeding of laparoscopic cholecystectomy. The overall mortality and morbidity associated with the procedure can be measured through such pre-operative parameters. This study was done to propose a pre-operative scoring method for assessing the easiness of laparoscopic cholecystectomy. Materials and Methods: A cohort study was conducted for patients admitted to a government hospital to undergo laparoscopic cholecystectomy. They were interviewed with a series of question and data were collected from the operation noted of the same patients. These were compared to the per-operative findings and easiness of surgery. Results: Body mass index, number of previous attacks more than 2, thickened gall bladder and total white blood cell count > 10,000 were noted as significant predictors for assessing the easiness in doing laparoscopic cholecystectomy. Conclusions: It is possible to predict the easiness of surgery in laparoscopic cholecystectomy using a pre-operative scoring system.
Keywords: Laparoscopic cholecystectomy, predictive factors, pre-operative scoring method
|How to cite this article:|
Lal T, Oommen A, Manjush E. Pre-operative scoring method for assessing the easiness of laparoscopic cholecystectomy. Kerala Surg J 2020;26:208-11
| Introduction|| |
Cholelithiasis is the presence of gall stones formed by the sedimentation of bile in the gall bladder (GB). Cholelithiasis may have four stages which are: lithogenic stage, asymptomatic stage, symptomatic stage and complicated cholelithiasis. Diagnostic modalities for detecting cholelithiasis include a wide spectrum ranging from clinical to sophisticated radiodiagnostic methods. One of the most common and widely used tests is ultrasonogram. In ultrasonogram, highly reflective echogenic focus within GB lumen, normally with prominent posterior acoustic shadowing shows the presence of calculi in the GB. Thickness of the GB wall and evidence of any pericholecystic fluid also can be identified by the ultrasonogram. Laparoscopic cholecystectomy is now the gold standard treatment modality for cholelithiasis. Pre-operative parameters influencing the operative procedure, the major factors that are in play and which can be assessed preoperatively are body mass index (BMI), number of previous hospital admissions, total white blood cell (WBC) count and GB wall thickness. The prevalence of obesity is higher in population estimates of laparoscopic cholecystectomy. A higher BMI is possibly associated with higher hospital resource utilisation, medical costs and allied health costs in those who underwent laparoscopic cholecystectomy. In a setting of inflammation produced by the gall stone disease the blood leucocyte count increases. In acute cholecystitis, the neutrophil count is elevated and in turn reflects the amount of inflammation. Persistent increase in neutrophils or the neutrophil count that is persistently in the higher normal levels shows the presence of chronic cholecystitis. The risk of conversion to open is significantly greater in patients associated with a greater leucocyte count. The number of previous attacks of acute cholecystitis is assessed by the number of hospital admissions and episodes of abdominal pain, leading to the development of chronic calculous cholecystitis. Statistically, the patient with more than 5 attacks of pain had significantly more difficulties in dissecting GB. GB wall thickness more than 4 mm is considered significant and studies shows that the this leads to difficulties in grasping the GB and also increases the chance of GB rupture and bile spillage.
The study was aimed to identify the pre-operative factors that lead to the occurrence of difficulties during laparoscopic cholecystectomy. The objectives were to study the relation between pre-operative parameters such as BMI, number of previous attacks, total count and wall thickness of GB; with the operative parameters such as time taken for surgery, bile spillage, conversion to open procedure and haemorrhage from cystic artery.
| Materials and Methods|| |
We formulated a pre-operative scoring method to assess the easiness in doing the laparoscopic cholecystectomy. It was a cohort study, conducted in the Department of General Surgery after getting approval from hospital ethical committee from January 2018 to June 2019. The sample size was calculated as 100 patients. All patients who underwent laparoscopic cholecystectomy were included. Patients unwilling to take part in the study were excluded. Patients included were interviewed with a series of questions and intraoperative details were collected from the operation notes. The association between the pre-operative parameters and intraoperative parameters was assessed. The sensitivity and specificity of the scoring method were assessed.
| Results|| |
Correlation study of the BMI and time taken for surgery >2 h indicated a significant P = 0.009. Sixteen obese patients with BMI more than 25 (43.2%) took more than 2 h for surgery as against 12 (19.0%) non-obese patients. It implies that BMI has significant association with increased time of surgery. Correlating the BMI and haemorrhage from cystic artery, 9 obese patients (24.3%) versus 13 normal (20.6%) patients showed a P = 0.667, implying that BMI has no significant association with the intraoperative haemorrhage from cystic artery. Studying the relation between BMI and bile spillage from cystic duct during laparoscopic cholecystectomy, it was observed that 9 obese patients (24.3%) versus 11 non-obese patients (17.5%), there was no statistical significance of difference with a P = 0.407, implying that BMI has no significant association with the bile spillage from cystic duct. Fisher's exact test was done to assess the association between BMI and conversion to open surgery and it showed no statistical significance between 5 obese patients (13.5%) versus 2 normal individuals (3.2%) with a P = 0.098, implying that BMI has no association with conversion to open surgery. However, all the risk parameters were higher in number in the high BMI group compared to the others as depicted in [Figure 1].
Correlation between number of previous attacks more than two times and time taken for surgery >2 h was considered. Thirteen (50%) of the multiple attack patients took >2 h of surgery against and 15 (20.3%) of the lesser attack group. The Chi-square test gave a P = 0.004, which indicates that there is a strong association between the number of previous attacks occurring more than two times and increased operative time. Relating the multiple attack patients with haemorrhage from cystic artery during laparoscopic cholecystectomy, it was seen that 11 (42%) of this group developed haemorrhage against 11 (14.9%) of the lesser attack group. The Chi-square test gave a P = 0.004, indicating a strong association between the multiple previous attacks and occurrence of haemorrhage from cystic artery. Similar to the above, bile spillage from cystic duct was also more in the multiple attack group with 9 (34.6%) against 11 (14.9%) of the lesser attack group. The Chi-square test gave a P = 0.03, which implies a statistically significant association between the previous multiple attacks and possibility of bile spillage from cystic artery. Likewise, the need for conversion to open surgery was statistically significantly more – 5 (19.2%) in the multiple episode group against 2 (2.7%) in the lesser attack group as shown by the Fisher's exact test with a P = 0.01, implying a strong association. All the correlations between multiple attack patients and the possibility of surgical difficulties during laparoscopic cholecystectomy are depicted in [Figure 2].
|Figure 2: No of previous attacks of cholecystitis with intraoperative parameters|
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Correlating the association between thickness of GB wall and increased operative time, it was seen that 12 (42.9%) of the thick wall group took more than 2 h for surgery against 16 (22.2%) of the thin wall group. This difference was statistically significant with Chi-square test giving a P = 0.04. The thick wall group however did not develop more haemorrhage 6 (21.4%) against the thin wall group – 16 (22.2%). Chi-square test gave a P = 0.931, implying that there is no association between thickness of GB wall and haemorrhage from cystic artery. Bile spillage from cystic duct was more in the thick wall group – 10 (35.7%) against 10 (13.9%) in the thin wall group with a statistically significant P = 0.014, by the Chi-square test, indicating a significant association between thickened GB wall and bile spillage from cystic duct. There is no significant association between thickness of GB wall and need for conversion to open surgery − 4 (14.3%) in the thick wall group against 3 (4.2%) in the thin wall group with Fisher's exact test giving a P = 0.094. All the above correlations between thickness of GB and surgical problems during laparoscopic cholecystectomy are depicted in [Figure 3].
Trying to correlate the association between total WBC count and increased operative time, it was seen that 4 (28.6%) of the leucocytosis group (WBC count >10,000/cmm) did not show and statistically significant difference (P = 1) against 24 (27.9%) of the normal WBC (<10,000/cmm) group as shown by Chi-square test. The leucocytosis group however developed more haemorrhage 6 (42.9%) than the normal WBC group – 16 (18.6%), Chi-square test showing a P = 0.042, implying that there is statistically significant association between leucocytosis and haemorrhage from cystic artery. Bile spillage from cystic duct was not significantly more in the leucocytosis group there is no significance association between increased leucocyte count and bile spillage from cystic artery 4 (28.6%) against 16 (18.6%) in the normal WBC group. Fisher's exact test gave a P = 0.471. There was no significant association between leucocytosis and need for conversion to open surgery − 3 (21.4%) against 4 (4.7%) in the normal WBC group with Fisher's Exact test giving a P = 0.06. All the above correlations between leucocytosis and surgical problems during laparoscopic cholecystectomy are depicted in [Figure 4].
We prepared a pre-operative scoring system with one point for BMI >29.9, three points for the number of previous attacks of cholecystitis >2, one point for total WBC count >10,000 and two points for thickened GB wall. From the total points obtained, we classified the patients into two, those with three or less points (82) and those with four or more (18). After the surgical procedure, the cases were categorisation into easy surgery (time taken for surgery <2 h, no haemorrhage from cystic artery and no bile spillage from cystic duct) and difficult surgery (1. time taken for surgery >2 h, 2. haemorrhage from cystic artery, 3. bile spillage from cystic duct or 4. conversion to open surgery, 1st three present or anyone present along with four). Eighty-five were easy and 15 were difficult cases. Specificity and sensitivity of scoring system were measured [Table 1]. Sensitivity was 91.8% and specificity was 73.3%.
| Conclusions|| |
Obesity is having strong association with increased operation time. The number of previous attacks more than 2 is the strongest predictor of difficulty in laparoscopic cholecystectomy as it has significant association with increased operating time, haemorrhage from cystic artery, bile spillage from cystic duct and increased conversion rate. Thickened GB wall has association with increased operating time, bile spillage from cystic duct. WBC count >10,000 had significant association with haemorrhage from cystic artery. Proposed scoring system is a reliable method to predict the easiness of laparoscopic cholecystectomy with a sensitivity of 91.8% and the specificity in predicting difficult cases is 71.3%. Further prospective trials using this scoring system would be needed in future.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]