2018 SSAT POSTER PRESENTATION
A Retrospective and Prospective Study to Develop a Pre-operative
Difficulty Score for Laparoscopic Cholecystectomy
Rami W Radwan
Ali Adel Ne’ma Abdullah
Received: 7 March 2018 / Accepted: 15 May 2018
2018 The Society for Surgery of the Alimentary Tract
Background The objectives of this study were to develop a grading system to enable pre-operative prediction of technical
difficulty of laparoscopic cholecystectomy using retrospective data and to attempt to validate our scoring system prospectively.
Methods Retrospective analysis was conducted of 100 consecutive patients. Pre-operative variables were collected based on a
template devised by the American College of Surgeons. Outcomes were duration of surgery, conversion to open and post-
operative complications. Multivariate analysis with subsequent measurement of hazard ratios was used to formulate a weighted
grading system. Prospective analysis was performed of 100 consecutive patients who were scored pre-operatively. Outcomes
were duration of surgery and length of stay.
Results Retrospective univariate analysis identified four variables associated with an increase in duration of surgery: male gender
(p = 0.023), age (p = 0.000), body mass index (BMI) (p = 0.000) and pre-operative endoscopic retrograde
cholangiopancreatography (ERCP) (p = 0.001). Prospective analysis revealed weak positive correlations between the scoring
system and duration of surgery (0.34) and length of stay (0.40).
Conclusion We have identified four pre-operative variables that predicted a longer duration of surgery. Preliminary results
suggest a positive correlation between this scoring system and duration of surgery. An adequately powered prospective multi-
centre study is needed to validate our findings.
Keywords Cholecystectomy, laparoscopic
The prevalence rate of gallstones is about 10–12% population
in European populations.
Over 20 million people suffer from
gallbladder disease in the USA.
my is now considered the gold standard approach in the
management of these patients, with improved post-operative
morbidity and mortality over open procedures.
Different factors have been associated with increased tech-
nical difficulty in laparoscopic cholecystectomy. Male pa-
tients have been shown to accumulate more infra-mesocolic
perivisceral fat, do not benefit from oestrogen suppression of
macrophages and generate a more intense inflammation and
fibrosis resulting in a technically more challenging
Older patients, often with increasing co-
morbidities and potentially longer histories of gallbladder dis-
ease, have been shown to have more complicated inflamed or
scarred tissue which can be difficult to dissect.
a higher body mass index (BMI) introduce technical difficul-
ties such as initial device implantation and obscure anatomy.
Patients who have had previous endoscopic retrograde
cholangiopancreatography (ERCP) or previous surgery have
also been suggested to pose a greater challenge to the operat-
These factors increase the risk of injury and
impede surgical flow.
Accepted for Presentation at Digestive Disease Week (DDW) (SSAT
Biliary Tract Diseases III), Washington DC (2–5th June 2018)
Presented at Association of Upper Gastrointestinal Surgeons of Great
Britain and Ireland (AUGIS) 20th Annual Scientific Meeting 2017,
Rochestown Park Hotel, Cork (21–22nd September 2017)
Presented at Welsh Surgical Society 2017 Autumn Meeting, The Coldra
Court Hotel, Newport (23–24th November 2017)
* Yousef Ibrahim
Gwent Centre for Digestive Diseases, Royal Gwent Hospital,
Newport, Wales NP20 2UB, UK
Journal of Gastrointestinal Surgery