I[NTRODUCTION]{.smallcaps} {#sec1-1}
==========================

Cholecystitis can occur suddenly, with symptoms such as fever along with intense pain in the right upper quadrant.\[[@ref1]\] Laparoscopic cholecystectomy (LC) has now become the gold standard for the treatment of symptomatic gallstones.\[[@ref2][@ref3]\] LC may be rendered difficult by various challenges encountered during surgery such as difficulties in accessing the peritoneal cavity, creating a pneumoperitoneum, dissecting the gallbladder, or extracting the excised gallbladder.\[[@ref4]\] Various parameters have been studied extensively to analyze their effects on LC, starting from a single variable to up to 34 parameters which include age, sex, acute attack requiring hospitalization, previous abdominal surgeries, presence of palpable gallbladder mass, presence of an abdominal scar, and BMI of the patient. Age is recognized as a risk factor for conversion, perhaps due to a long history of gallstone and increased number of cholecystitis attacks.\[[@ref5]\] It has been observed that surgeons encountered difficulties while performing LC when there are dense adhesions at Calot\'s triangle, fibrotic and contracted gallbladder, acutely inflamed or gangrenous gallbladder and cholycystoenteric fistula, etc.\[[@ref6]\] Various available literature suggest that male gender is a high-risk factor for difficult LC. Previous upper abdominal surgery has been listed as a poor predictor for safe LC because of adhesion formations. It may also pose a problem in creating pneumoperitoneum, thus making LC difficult.\[[@ref7][@ref8][@ref9]\]

Abdominal ultrasound has become a reliable, quick, and noninvasive tool to diagnose gallstone disease.\[[@ref10]\] Apart from its value in diagnosis, its findings may also predict the degree of difficulty involved in the procedure. One of the important ultrasonographic findings is maximum gallbladder wall thickness of \>4 mm which indicates a contracted fibrotic gallbladder which is difficult to grasp. Apart from this, ultrasound also demonstrates a porcelain gall bladder, gallbladder-containing large impacted stone, especially in Hartmann\'s pouch. Pericholecystic collection implies inflammation around the gallbladder which makes LC difficult.\[[@ref11]\]

History of previous attacks, nonvisualization of the gallbladder, pericholecystic, and peripancreatic fluid are associated with a significant inflammatory process that causes difficulty in the dissection of Calot\'s triangle and adhesiolysis.\[[@ref12]\]

Abnormal liver function tests and elevated amylase may signify ongoing hepatitis, cholangitis, and pancreatitis that pose difficulty in dissection due to edema.\[[@ref13]\]

This study was designed to know the preoperative safe predictors for LC based on various parameters which include age, sex, acute attack requiring hospitalization, deranged liver functions, and ultrasonographic findings. The level of difficulty predicted preoperatively based on these parameters was compared with the actual challenges encountered during the laparoscopic procedure. During the procedure, the level of difficulty encountered was categorized by developing a scoring system \[[Table 1](#T1){ref-type="table"}\], which is expected to help surgeons in making unbiased standard predictions.

###### 

Local grading

  Grading                           Parameters
  --------------------------------- ---------------------
  Easy                              Time taken \<60 min
  No injury to duct or artery       
  No conversion to open             
  Reasonably easy                   Time taken \>60 min
  No Injury to duct or artery       
  No conversion to open             
  Moderately difficult              Time taken \<60 min
  Injury to duct or artery          
  No conversion to open             
  Difficult                         Time taken \>60 min
  Injury to duct or artery          
  No conversion to open             
  Very difficult                    Time taken \>60 min
  No Injury to duct or artery       
  Conversion to an open procedure   
  Severely difficult                Time taken \>60 min
  Injury to duct or artery          
  Conversion to an open procedure   

M[ATERIALS AND]{.smallcaps} M[ETHODS]{.smallcaps} {#sec1-2}
=================================================

This prospective study was conducted on 100 patients of either sex and of all age groups with a diagnosis of cholecystitis, over a 2-year period from January 1, 2017, to December 31, 2018. Preoperatively, a thorough history and physical examination were done in all patients. All required investigations, including Complete Blood Count (CBC), liver function tests, renal function tests, coagulation profile, serum amylase, serum lipase, and ultrasonography (USG), were carried out. LC was carried out, and intra-operative details were observed. Scores were given \[[Table 1](#T1){ref-type="table"}\], based on various parameters, which included time taken for the procedure, biliary or stone spilling, injury to the duct or artery, and conversion to open cholecystectomy, were recorded on a predesigned pro forma.

Inclusion criteria {#sec2-1}
------------------

Patients with cholecystitis confirmed by USG for the presence of gallstones.

Exclusion criteria {#sec2-2}
------------------

Patients with mass formation after an attack of acute cholecystitisPatients having coagulation disordersPregnant patientsPatients not giving consent or unfit for general anesthesia.

Various parameters {#sec2-3}
------------------

Various parameters such as age, sex, previous attacks, previous surgery, deranged liver function tests, contracted or distended gallbladder, pericholecystic fluid, multiple stones, and gangrenous gallbladder were analyzed for predicting safe LC.

Chi-square test and *P* value were used to determine the statistical significance.

R[ESULTS]{.smallcaps} {#sec1-3}
=====================

Age {#sec2-4}
---

Minimum age of the patient undergoing LC was 22 years, and the maximum was 70 years. In the present study, 75% were in the age group of 31--60 years and the mean age was 43.44 ± 1.13 years \[[Table 2](#T2){ref-type="table"}\]. On analyzing the age data statistically \[[Table 3](#T3){ref-type="table"}\], it was observed that the preoperative prediction was correct in 100.0% of cases predicted as easy in the age group of ≤65 years, whereas 25.0% of the cases were correctly predicted as difficult in the age group of \>65 years.

###### 

Age-wise distribution of patients

  Age groups (years)   Number of patients (%)
  -------------------- ------------------------
  21-30                18 (18.0)
  31-40                31 (31.0)
  41-50                27 (27.0)
  51-60                15 (15.0)
  61-70                9 (9.0)
  \>70                 0 (0.0)
  Total                100 (100.0)
  Mean age             43.44±1.13
  Range                22-70

###### 

Correlation of age with peroperative outcome

  Age group (years)   Outcome, *n* (%)   Total, *n* (%)                                               
  ------------------- ------------------ ------------------ ---------- ---------- --------- --------- -----------
  ≤65                 71 (100)           11 (78.6)          5 (83.3)   3 (75.0)   3 (100)   2 (100)   95 (95.0)
  \>65                0 (0.0)            3 (21.4)           1 (16.7)   1 (25.0)   0 (0.0)   0 (0.0)   5 (5.0)
  Total               71 (100)           14 (100)           6 (100)    4 (100)    3 (100)   2 (100)   100 (100)
                                                                                                      
  ***χ*^2^**          ***P***            **Significance**                                             
                                                                                                      
  17.043              0.004              HS                                                           

HS: Highly significant

Sex {#sec2-5}
---

In the present study, 79.0% were female \[[Table 4](#T4){ref-type="table"}\]. It was observed that of 79 females, 4 cases were found to be moderately difficult, 2 cases were found to be difficult, and 1 case was found to be very difficult as per the criteria in this study. While in males, of 21 cases, 2 were found to be moderately difficult, 2 were found to be difficult, and 2 were found to be very difficult.

###### 

Sex distribution of patients

  Sex distribution   Number of patients (%)
  ------------------ ------------------------
  Male               21 (21.0)
  Female             79 (79.0)
  Total              100 (100)

Previous attacks of cholecystitis {#sec2-6}
---------------------------------

Twenty-four cases had a history of previous attacks of cholecystitis ranging from mild-to-moderate intensity lasting for 1--2 days. Eight patients were hospitalized and treated with parenteral medications for 2--3 days. On analyzing the data statistically \[[Table 5](#T5){ref-type="table"}\], of 24 cases who had previous attacks, 5 came out to be moderately difficult; whereas of 76 cases that never had any previous attack, one came out to be moderately difficult.

###### 

Previous attacks of cholecystitis

  Previous attacks   Outcome, *n* (%)   Total, *n* (%)                                                 
  ------------------ ------------------ ------------------ ---------- ---------- ---------- ---------- -----------
  Yes                4 (5.6)            11 (78.6)          5 (83.3)   2 (50.0)   1 (33.3)   1 (50.0)   24 (24.0)
  No                 67 (88.2)          3 (21.4)           1 (16.7)   2 (50.0)   2 (66.7)   1 (50.0)   76 (76.0)
  Total              71 (100)           14 (100)           6 (100)    4 (100)    3 (100)    2 (100)    100 (100)
                                                                                                       
  ***χ*^2^**         ***P***            **Significance**                                               
                                                                                                       
  49.935             \<0.001            HS                                                             

HS: Highly significant

Deranged liver function tests {#sec2-7}
-----------------------------

About 83.3% of the patients predicted as moderately difficult and 66.7% of the patients predicted as very difficult peroperatively had deranged liver function tests \[[Table 6](#T6){ref-type="table"}\].

###### 

Deranged liver function tests

  Deranged LFT   Outcome, *n* (%)   Total, *n* (%)                                               
  -------------- ------------------ ------------------ ---------- --------- ---------- --------- -----------
  Yes            2 (2.8)            12 (85.7)          5 (83.3)   4 (100)   2 (66.7)   2 (100)   27 (27.0)
  No             69 (97.2)          2 (14.3)           1 (16.7)   0 (0.0)   1 (33.3)   0 (0.0)   73 (73.0)
  Total          71 (100)           14 (100)           6 (100)    4 (100)   3 (100)    2 (100)   100 (100)
                                                                                                 
  ***χ*^2^**     ***P***            **Significance**                                             
                                                                                                 
  73.831         \<0.001            HS                                                           

LFT: Liver function test, HS: Highly significant

Ultrasonographic findings {#sec2-8}
-------------------------

On analyzing the data statistically \[[Table 7](#T7){ref-type="table"}\], 25.0% of the patients predicted as difficult peroperatively and 66.7% of the patients predicted as very difficult peroperatively had contracted gallbladder on ultrasound and 25.0% of the patients predicted as difficult peroperatively and 33.3% of the patients predicted as very difficult peroperatively had distended gallbladder on ultrasound, whereas 85.9% of the patients predicted as easy preoperatively had normal gallbladder distension. On analyzing the data statistically \[[Table 8](#T8){ref-type="table"}\], 33.3% of the patients predicted as moderately difficult peroperatively had pericholecystic fluid on ultrasound and 66.7% of the patients predicted as moderately difficult peroperatively had no pericholecystic fluid on ultrasound.

###### 

Ultrasonographic findings

  Ultrasonographic findings   Outcome, *n* (%)   Total, *n* (%)                                                 
  --------------------------- ------------------ ------------------ ---------- ---------- ---------- ---------- -----------
  Contracted                  4 (5.6)            6 (42.9)           1 (16.7)   1 (25.0)   2 (66.7)   1 (50.0)   15 (15.0)
  Distended                   6 (8.5)            7 (50.0)           4 (66.7)   1 (25.0)   1 (33.3)   0 (0.0)    19 (19.0)
  No                          61 (85.9)          1 (7.1)            1 (16.7)   2 (50.0)   0 (0.0)    1 (50.0)   66 (66.0)
  Total                       71 (100)           14 (100)           6 (100)    4 (100)    3 (100)    2 (100)    100 (100)
                                                                                                                
  ***χ*^2^**                  ***P***            **Significance**                                               
                                                                                                                
  53.880                      \<0.001            HS                                                             

HS: Highly significant

###### 

Pericholecystic fluid

  Pericholecystic fluid   Outcome, *n* (%)   Total, *n* (%)                                               
  ----------------------- ------------------ ------------------ ---------- ---------- --------- --------- -----------
  Yes                     4 (5.6)            11 (78.6)          2 (33.3)   2 (50.0)   3 (100)   2 (100)   24 (24.0)
  No                      67 (94.4)          3 (21.4)           4 (66.7)   2 (50.0)   0 (0.0)   0 (0.0)   76 (76.0)
  Total                   71 (100)           14 (100)           6 (100)    4 (100)    3 (100)   2 (100)   100 (100)
                                                                                                          
  ***χ*^2^**              ***P***            **Significance**                                             
                                                                                                          
  53.590                  \<0.001            HS                                                           

HS: Highly significant

D[ISCUSSION]{.smallcaps} {#sec1-4}
========================

In the present study, 75% of patients were in the age group of 31--60 years and the mean age was 43.44 ± 1.13 years. This can be explained by the fact that the study was conducted on patients of symptomatic cholelithiasis undergoing LC, which is a disease of the middle age. On analyzing the age data statistically \[[Table 3](#T3){ref-type="table"}\], it was observed that the preoperative prediction was correct in 100.0% of cases predicted as easy in the age group of ≤65 years, whereas 25.0% of the cases were correctly predicted as difficult in the age group of \>65 years. It was observed that older age (\>65 years) was a significant risk factor for difficult LC (*P* = 0.004). The increase in difficulty with age has been reported by many authors. Kanaan *et al.*\[[@ref14]\] gave older male as one of the main factors of conversion of LC to open cholecystectomy. Our results were similar in comparison to the other studies by Kanaan *et al.*\[[@ref14]\] and Gabriel *et al.*\[[@ref15]\] with age \> 65 years being a significant risk factor. However, Gupta *et al.*\[[@ref16]\] and Fried *et al.*\[[@ref17]\] in their study had found that age was not a significant factor.

In our study, 79.0% of the patients were female. This higher incidence in females can be attributed to the fact that cholelithiasis is more common in females. In analyzing the data, it was found that the preoperative prediction in females was correct in 88.7% of the cases predicted as easy, whereas in males, preoperative prediction for difficulty was correct for 50.0% of cases and for a very difficult challenge was correct for 66.7% of cases. Although cholelithiasis is more common in females, males had higher risks of having difficult LC due to more intense inflammation or fibrosis to result into a difficult dissection in the Calot\'s triangle and the gallbladder bed as was reported by Lein and Huang.\[[@ref7]\]

We found that of 24 cases who had previous attacks, 5 came out to be moderately difficult. A significant correlation was seen between previous attacks of cholecystitis and some difficulties encountered during LC. Like the present study, many researchers such as Gabriel *et al.*,\[[@ref17]\] Gupta *et al.*\[[@ref16]\] and Nachnani and Supe\[[@ref18]\] had found that the history of the previous hospitalization was a predictor for difficult cholecystectomy and higher conversion rate due to dense fibrotic adhesions, bleeding, and ductal injuries.

The deranged liver function tests and elevated serum amylase (ongoing cholangitis, hepatitis, and pancreatitis) were significant predictors for difficult LC (Chi-square = 73.831) and (*P* \< 0.001), due to difficult dissection because of edema, and this finding was in accordance with the study of Alponat *et al.*\[[@ref13]\]

The USG findings such as contracted gallbladder, distended gallbladder, multiple stones, and pericholecystic collection were observed significant risk factors (Chi-square = 53.880), (*P* \< 0.001), because these factors caused significant difficulty in grasping of gallbladder, adhesiolysis as well as dissection of Calot\'s triangle and dissection of gallbladder from liver bed. These findings are consistent with observations of Singh and Ohri.\[[@ref19]\]

C[ONCLUSIONS]{.smallcaps} {#sec1-5}
=========================

LC has become the gold standard in the treatment of symptomatic gallstone disease. Elderly patients are more likely to have a difficult LC. Cholecystitis is more common in females, but difficulties are encountered more frequently while performing LC in males. Patients with recurrent cholecystitis tend to have more difficulties during surgery. Abnormal serum hepatic and pancreatic enzyme profiles are associated with difficulty in surgery. The preoperative USG can well predict difficulties during LC. Features like distended or contracted gallbladder are associated with subsequent difficulties during the surgery.

LC though mostly safe and uneventful can be difficult at times. What an inexperienced laparoscopic surgeon may consider difficult, the experienced laparoscopic surgeon may consider that to be very simple. With increasing experience selection criteria for LC has become more liberal, it is being used in more and more earlier contraindicated situations. In these circumstances, a lot of problems can be avoided by correct preoperative prediction of difficult cholecystectomy.

Financial support and sponsorship {#sec2-9}
---------------------------------

Nil.

Conflicts of interest {#sec2-10}
---------------------

There are no conflicts of interest.
