European Journal of Cardiovascular Medicine

One popular surgical procedure used to treat gallstones is cholecystectomy. In certain situations, though, it might be difficult, which raises morbidity and mortality. This study's objective is to assess the risk variables for challenging cholecystectomy. Gallstone disease, also known as cholelithiasis, is one of the most common biliary ailments in the world and has a major effect on public health. [1] Gallstones are thought to afflict 20 million people in the United States alone, and about 1 million new cases are diagnosed each year. [2] There is significant geographic and demographic variation in occurence; research suggests that it affects about 4% of Indians, a number that is increasing in tandem with the westernization of lifestyle and food practices. Cholelithiasis has a complex pathophysiology that includes environmental factors, metabolic diseases, and genetic predispositions.The interaction between dietary inputs and physiological reactions before and after meals is crucial to its growth because it can cause bile to become supersaturated and cholesterol crystals to form if it is disturbed. [3] Episodic biliary colicky pain, usually confined to the right upper quadrant and often spreading to the epigastric area, back, or shoulder, is a common clinical feature of cholelithiasis. [4] Although a significant number of people with gallstones do not experience any symptoms, it is important to note that roughly 20–25% may experience severe side effects that require immediate medical attention, such as acute cholecystitis, choledocholithiasis, cholangitis, biliary pancreatitis, or even gallstone ileus. [5] Traditionally, the standard treatment for gallbladder disease was open cholecystectomy (OC).  The treatment of cholelithiasis has been completely transformed by the development of laparoscopic procedures, which provide a less intrusive option with several therapeutic benefits. [6] The benefits of laparoscopic cholecystectomy (LC), which include less surgical trauma, less postoperative pain, shorter hospital stays, and accelerated recovery, have been highlighted by the National Institutes  of  Health  (NIH)  Consensus  Development  Conference,  which  has  identified laparoscopic cholecystectomy as the most effective modality for managing this condition. [7]

However, complications from laparoscopic cholecystectomy, like extended operating time, bile or stone spills, and the possibility of converting to open surgery, necessitate a comprehensive study of predicted factors that can give indication of difficulty surgery. By identifying these parameters, surgeons can improve patient safety during laparoscopic procedures, optimize resource allocation, and facilitate successful preoperative planning. [8].Aim of our study was, to evaluate the prevalence of difficult cholecystectomy, to identify the predictive factors for difficult cholecystectomy, to evaluate the relationship between these factors and the outcome of the surgery.

Study Design: This is a prospective observational study

Study Settings: The study was conducted in the Department of General Surgery of a tertiary care teaching hospital.  A total of 272 patients undergoing elective laparoscopic cholecystectomy were included. Preoperative evaluation and imaging were done to identify predictive factors. Intraoperative findings were analyzed to assess the difficulty of surgery.

Place of Study: PCS Government Medical College & Hospital, Arambagh, Hooghly, West Bengal.

Period of Study: 1 year (July 2024 to June 2025)

Study Population:The study population was consist of patients undergoing cholecystectomy at our hospital who full fills our inclusion criteria. Data was collected from the patients' medical records and through a questionnaire and we have used Modified Randhawa et all Scoring System to predict difficult Laparoscopic Cholecystectomy Pre Operatively.

Sample Size: 272 who underwent Laparoscopic cholecystectomy and full filled inclusion criteria.

• Patient underwent elective or emergency laparoscopic cholecystectomy at PCS Govt.Medical College & Hospital, Arambagh, Hooghly, West Bengal.
• Patients aged 18 years and
• Patients who provide informed

Exclusion Criteria

• Patients undergoing cholecystectomy for reasons other than gallstones (e.g.gallbladder cancer).
• Patients with a history of previous partial
• Patients with a history of liver disease or liver
• Patients who are pregnant or
• Patients who are unable to provide informed
• Pregnant mother

Study Variables

• Age
• Sex
• Body Mass Index (BMI)
• History of acute cholecystitis
• History of previous abdominal surgery
• Presence of comorbidities

Statistical Analysis:-

For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analysed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while Data were entered into Excel and analysed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered stat istically significant.

Table 1: Distribution of Preoperative Predective factors for Difficult Laparoscopic Cholecystectomy

Table 2: Distribution of: Preoperative Prediction of Difficulty Levels According to Scoring System (n = 272)

Table 3: Distribution of: Intraoperative Scoring Factors in Laparoscopic Cholecystectomy

Table 4: Association between Comparison of CT scan Findings between Difficult and Not Difficult LC Groups

Figure 1: Preoperative Prediction of Difficulty Levels According to Scoring System

In our study a total of 88 patients (32.4%) were aged over 60 years (p = 0.014), and 102 patients (37.5%) were male (p = 0.028), both showing statistically significant correlation with increased surgical difficulty. Elevated BMI (>27.5 kg/m²) was noted in 76 patients (27.9%) and was significantly associated with difficult procedures (p = 0.041). A history of acute cholecystitis was reported in 64 patients (23.5%), with a strong statistical significance (p < 0.001). Additionally, palpable gallbladder on clinical examination was observed in 42 patients (15.4%), also showing a significant correlation (p = 0.049).In our study of 272 patients, 152 (55.9%) had a total preoperative score of 0–2 indicating an easy laparoscopic cholecystectomy, 88 (32.4%) had a score of 3–4 indicating a difficult surgery, and 32 (11.7%) had a score ≥5 suggesting a very difficult procedure or conversion to open surgery, with the distribution being statistically significant (p < 0.001).In our study, Adhesions at Calot’s triangle were observed in 98 patients (36.0%, p < 0.001), and abnormal gallbladder appearance was noted in 86 patients (31.6%, p = 0.003). Gallbladder distension or contraction was present in 70 patients (25.7%, p = 0.017), while difficulty in identifying anatomy occurred in 48 patients (17.6%, p < 0.001). Bleeding during dissection was seen in 36 patients (13.2%, p = 0.008), and spillage of bile or stones was noted in 40 patients (14.7%, p = 0.031). Gallbladder immobility was reported in 64 patients (23.5%, p = 0.009), and conversion to open cholecystectomy was required in 12 patients (4.4%, p < 0.001).In our study, among the 136 patients who underwent not difficult laparoscopic cholecystectomy, gallbladder wall thickening ≥4 mm was observed in 28 patients (20.6%), pericholecystic fat stranding in 22 (16.2%), impacted gallstone at the neck in 20 (14.7%), and gallbladder distension >10 cm in 18 patients (13.2%). Additionally, pericholecystic collection was seen in 16 patients (11.8%), contracted gallbladder in 12 (8.8%), and dilated common bile duct (CBD >6 mm) in 10 patients (7.4%).In contrast, among the 136 patients with difficult laparoscopic cholecystectomy, gallbladder wall thickening ≥4 mm was significantly more common, seen in 64 patients (47.1%, p < 0.001), pericholecystic fat stranding in 58 (42.6%, p < 0.001), and impacted gallstone at the neck in 52 (38.2%, p < 0.001). Gallbladder distension >10 cm was noted in 44 patients (32.4%, p < 0.001), pericholecystic collection in 34 (25.0%, p = 0.004), contracted gallbladder in 28 (20.6%, p = 0.009), and dilated CBD in 22 patients (16.2%, p = 0.031), all showing statistically significant associations with increased surgical difficulty.

We found that several preoperative factors were significantly associated with difficult laparoscopic cholecystectomy among the total 272 patients studied. Advanced age (>60 years) was observed in 88 patients (32.4%, p = 0.014), indicating increased operative difficulty in elderly individuals. Similar findings were reported by Jain et al., where increasing age correlated with difficult dissection due to fibrotic changes and poor tissue planes [9]. Male sex was noted in 102 patients (37.5%, p = 0.028), suggesting a higher likelihood of difficult surgery, possibly due to anatomical and inflammatory differences. This trend has also been confirmed in studies by Gupta et al. and Alponat et al., highlighting a higher conversion rate and longer operative times in males [10,11]. A BMI >27.5 kg/m² was present in 76 patients (27.9%, p = 0.041), reflecting technical challenges in obese individuals, which was supported by the findings of Yılmaz et al., who noted a significant correlation between obesity and surgical complexity [12]. History of acute cholecystitis was reported in 64 patients (23.5%, p < 0.001), showing a strong association with surgical difficulty, likely due to chronic inflammation and adhesions. This is consistent with the observations of CholeS Study Group, where acute cholecystitis significantly predicted operative difficulty [13]. A palpable gallbladder was identified in 42 patients (15.4%, p = 0.049), which may indicate underlying inflammation and distension contributing to technical challenges.

We observed that a higher percentage of patients fell into the easy category based on the total preoperative score. Out of 272 patients, 152 (55.9%) had a score range of 0–2, suggesting a lower risk of intraoperative difficulty. This distribution was statistically significant (p < 0.001), emphasizing the predictive value of preoperative scoring systems. Similar findings were reported by Singh et al., who found that patients with lower scores (0–2) had significantly easier laparoscopic cholecystectomies and fewer complications [14]. In another study, Sharma et al. validated a scoring system where 60% of patients with a score ≤2 underwent uncomplicated surgeries [15].

We observed that adhesions at Calot’s triangle were the most common intraoperative finding, present in 98 patients (36.0%, p < 0.001), often complicating dissection and increasing operative time. Similar results were reported by Gupta et al., where dense adhesions were the leading cause of conversion and prolonged surgery [10]. Abnormal gallbladder appearance was noted in 86 patients (31.6%, p = 0.003), while gallbladder distension or contraction was seen in 70 patients (25.7%, p = 0.017), both contributing to surgical difficulty. Sharma et al. emphasized that abnormal morphology of the gallbladder is a strong predictor of difficult dissection [15]. Difficulty in identifying anatomy occurred in 48 patients (17.6%, p < 0.001), reflecting a major risk for bile duct injury. Dey et al. reported that unclear anatomy was significantly associated with intraoperative complications and conversion [16]. Bleeding during dissection was observed in 36 patients (13.2%, p = 0.008), and spillage of bile or stones in 40 patients (14.7%, p = 0.031), both affecting visibility and increasing intraoperative risk. Limited gallbladder mobility was found in 64 patients (23.5%, p = 0.009), hampering surgical manipulation. Conversion to open cholecystectomy was necessary in 12 patients (4.4%, p < 0.001), in line with observations by Yadav et al., who reported conversion rates around 5% in difficult cases [17].

We observed that several preoperative CT scan findings were significantly more common in patients who experienced difficult laparoscopic cholecystectomy. Gallbladder wall thickening ≥4 mm was seen in 64 difficult cases (47.1%) compared to 28 non-difficult cases (20.6%) (p < 0.001), indicating chronic inflammation. Similar observations were reported by Kim et al., where thickened gallbladder walls were predictive of complicated cholecystitis and surgical difficulty [20]. Pericholecystic fat stranding was present in 58 (42.6%) of the difficult group versus 22 (16.2%) of the non-difficult group (p < 0.001), reflecting active inflammation—an important marker highlighted in the work of Singh et al. [14]. Impacted gallstone at the neck of the gallbladder was found in 52 (38.2%) difficult cases compared to 20 (14.7%) non-difficult cases (p < 0.001), contributing to obstruction and surgical complexity. Similar results were seen in the study by Dey et al., where impacted stones were significantly associated with difficult dissection and conversion [16]. Distended gallbladder (>10 cm) was seen in 44 (32.4%) of the difficult group versus 18 (13.2%) in the non-difficult group (p < 0.001), consistent with reports by Ahmed et al., who emphasized gallbladder distension as a predictor of intraoperative difficulty [18]. Pericholecystic collection was more common in difficult cases (25.0% vs 11.8%, p = 0.004), and contracted gallbladder also showed a significant difference (20.6% vs 8.8%, p = 0.009), both indicators of chronic disease progression. Dilated common bile duct (CBD >6 mm) was observed in 22 (16.2%) difficult cases compared to 10 (7.4%) in the non-difficult group (p = 0.031), supporting previous findings by Yildirim et al., who linked CBD dilation with underlying choledocholithiasis and prolonged operative time [19].

We concluded that a significant number of laparoscopic cholecystectomies were found to be challenging in this study, which included 272 patients. Several important preoperative predictors were identified. Increased surgical difficulty was associated with factors such as advanced age, male sex, high body mass index, a history of acute cholecystitis, and a visibly distended gallbladder. Preoperative CT findings, including gallbladder wall thickening, pericholecystic fat stranding, impacted stones, gallbladder distension, and pericholecystic collection, were also linked to more complex cases. Intraoperative challenges, such as adhesions at Calot’s triangle, abnormal gallbladder appearance, restricted mobility, bleeding, and bile spillage, further contributed to procedural complexity. The preoperative scoring system proved useful in distinguishing between easy and difficult cases, aiding in surgical planning and anticipation of potential risks.

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