A Study On Utility Of A Predictive Score In The Pre-Operative Prediction Of Difficult Laparoscopic Cholecystectomy
Dr.Aparna Venugopal1, Dr.R Balamurugan*1, Dr.Athira Gopinathan2, Dr.Sivamarieswaran2
Department of General Surgery, SRM Medical College and Hospital, SRM Institute of Science and Technology, Kattankulathur-603203
1-Post Graduate, Department of General surgery, SRM Medical College and Hospital, SRM Institute of Science and Technology, Kattankulathur-603203
*1-Professor and Unit Chief, Department of General surgery, SRM Medical College and Hospital, SRM Institute of Science and Technology, Kattankulathur-603203
2-Assistant Professor, Department of General surgery, SRM Medical College and Hospital, SRM Institute of Science and Technology, Kattankulathur-603203
ABSTRACT
Laparoscopic cholecystectomy is the gold standard surgical management of symptomatic gall stone disease.
Although it provides significant advantages over open cholecystectomy, it is a s s o c i a t e d w i t h m a n y c o m p l i c a t i o n s l i k e b i l e d u c t i n j u r y , s e p s i s , h a e m o r r h a g e , g a l l b l a d d e r p e r f o r a t i o n e t c . V a r i o u s s t u d i e s h a v e a t t e m p t e d t o u n d e r s t a n d t h e c o r r e l a t i o n b e t w e e n p r e - o p e r a t i v e f a c t o r s a n d t h e i n t r a o p e r a t i v e d i f f i c u l t y o f l a p a r o s c o p i c c h o l e c y s t e c t o m y . T h i s s t u d y w a s a i m e d a t a s s e s s i n g t h e u t i l i t y o f a s c o r i n g s y s t e m i n t h e a c c u r a t e p r e - o p e r a t i v e p r e d i c t i o n o f t h e i n t r a o p e r a t i v e d i f f i c u l t y o f s u r g e r y t o h e l p i n t h e d e c i s i o n m a k i n g p r o c e s s , t h u s r e d u c i n g t h e c o m p l i c a t i o n r a t e , r a t e o f c o n v e r s i o n , a n d o v e r a l l m e d i c a l c o s t . T h e p r e o p e r a t i v e s c o r i n g s y s t e m u s e d c o n s i s t e d o f v a r i a b l e s b a s e d o n h i s t o r y ( a g e , s e x , h / o p r e v i o u s h o s p i t a l i z a t i o n ) , c l i n i c a l e x a m i n a t i o n ( B M I , a b d o m i n a l s c a r , p a l p a b l e g a l l b l a d d e r ) , a n d r a d i o l o g i c a l i m a g i n g ( g a l l b l a d d e r w a l l t h i c k n e s s , p e r i c h o l e c y s t i c c o l l e c t i o n , i m p a c t e d s t o n e ) , e a c h o f w h i c h w a s a s s i g n e d a n i n d i v i d u a l s c o r e . T h e s u m s o f t h e i n d i v i d u a l s c o r e s w e r e c o m p u t e d , b a s e d o n w h i c h t h e c a s e s w e r e p r e d i c t e d t o b e e a s y , d i f f i c u l t o r v e r y d i f f i c u l t . F o l l o w i n g l a p a r o s c o p i c c h o l e c y s t e c t o m y , t h e i n t r a o p e r a t i v e d i f f i c u l t y w a s c a l c u l a t e d b y a s s e s s i n g t h e t o t a l t i m e t a k e n f o r t h e p r o c e d u r e , a n d f a c t o r s l i k e i n t r a o p e r a t i v e b i l e l e a k a n d i n j u r y t o c y s t i c d u c t / a r t e r y . I n t h i s s t u d y , t h e s c o r i n g s y s t e m a c c u r a t e l y p r e d i c t e d t h e d i f f i c u l t y o f s u r g e r y i n 9 3 o u t o f 9 7 ( 9 5 . 8 % ) c a s e s w i t h a s e n s i t i v i t y o f 9 6 . 5 1 % a n d s p e c i f i c i t y o f 1 0 0 % . O u t o f t h e p r e o p e r a t i v e f a c t o r s c o n s i d e r e d f o r t h e s c o r i n g s y s t e m , h i s t o r y o f p r e v i o u s a b d o m i n a l s u r g e r y , h i s t o r y o f p r e v i o u s h o s p i t a l a d m i s s i o n f o r c h o l e c y s t i t i s , u l t r a s o n o g r a p h i c f i n d i n g s l i k e p r e s e n c e o f p e r i c h o l e c y s t i c c o l l e c t i o n a n d i n c r e a s e d G B w a l l t h i c k n e s s w e r e f o u n d t o h a v e a v e r y h i g h p o s i t i v e c o r r e l a t i o n w i t h d i f f i c u l t y o f s u r g e r y , w h i l e a d v a n c i n g a g e h a d o n l y a m o d e r a t e p o s i t i v e c o r r e l a t i o n w i t h i n t r a o p e r a t i v e d i f f i c u l t y . B M I a n d g e n d e r d i d n o t a f f e c t t h e i n t r a o p e r a t i v e d i f f i c u l t y s i g n i f i c a n t l y i n t h i s s t u d y.
INTRODUCTI ON
Chol ecyst ect omy refers t o t he surgical procedure of rem oval of gall bl adder for choleli thi asis or chol ecystit is. In patients with symptom ati c gallstone diseas e, laparoscopic chol ecystect omy is now t hought to be the gold st andard i n surgical management( 1 ) ( 2 ). C arl Johan n August Langenbuch( 3 ) in 1882, carri ed
out the first success ful cholecystect omy in a pati ent wit h choleli thi asis . The first l aparos copi c chol ecyst ectomy in a hum an was performed by a French surgeon, P hilip Mouret in 1987( 4 ). It has vari ous advantages over open cholecystect omy, s uch as less er post -operati ve pai n, earli er ret urn of bowel functi on, s horter durat ion of hospit al st ay, bett er cosm esis and als o earlier recovery ( 5 ) ( 6 ). 2 –15 % of cases of l aparos copi c cholecyst ectomy requi re conversi on t o open pro cedure due to various di fficulti es encount ered i nt ra operativel y( 7 ).
Difficulty of the surgery increases in case of dense adhesions at the Calot’s tri angl e, acutely i nfl am ed and gangrenous gallbl adder, empyema gal lbl adder, pati ent s wit h history of previ ou s cholecys tost omy, chol ecystoduodenal/
cholecystogastric fistula, Mirizzi’s syndrome, and in patients with previous history of upper abdominal surgery( 8 ) ( 9 ). Laparos copic chol ecyst ectom y has many pos sibl e com plicati ons , including bile l eak, haem orrhage, bi l e duct injury, gall bl adder perforation, perihepat ic coll ection, sepsis , ext ernal bili ary fistula, hem atoma formation, foreign body inclusions, adhesi ons, m etast atic port -si te deposits , and cholelithoptysis( 1 0 ). However improvement in surgical expertis e an d recent advances i n equi pm ent have lowered the compli cation rat e in LC t o about 2 –6 %( 1 1 ). P reoperat ive factors such as ol d age, rais ed body mass index (B M I), previ ous hist ory of abdominal surgery, m al e gender, cholecystitis wit h fever, l eukocytosis, and ult rasonographi cal findi ngs like dist ensi on of t he gall bladder, t hickened gallbladder li ning, impacted s tone, and peri chol ecyst ic fluid coll ect ion, are al l risk fact ors predi spos ing t o diffi cult laparos copic chol ecystectom y( 1 2 ).
Kam a et al( 1 3 ) conduct ed a study which concluded t hat si x param et ers — advanci ng age, m ale gender, hi story of abdomi nal surgery, tendernes s in th e upper abdom en, s onographi call y diagnosed t hickened gallbl adder wall and th e preoperative di agnos is of acut e chol ecysti tis were signi fic antly associ at ed with the risk of conversi on t o open chol ecyst ectom y. In a st udy carri ed out by Lee et al., ( 1 4 ), it was concl uded that m al e sex, age >65 yrs, hi story of surgery to upper abdomen and previous hist ory of chol ecystiti s were all ris k fact ors f or conversi on. A preoperative scoring syst em bas ed on history, cli ni cal examinati on, and sonographi c fi ndings compared wi th the score given bas ed on intraoperative difficulti es ai ds i n predicting the di ffi culty of l aparos copi c cholecystect omy. A scoring sy st em woul d help in decidi ng t he appropri at e surgical approach, thus reducing t he complication rat e, rat e of conversi on, and overall medical cost( 1 5 ). Wi th t he assistance of accurat e predi ction, pati ents at high ri sk can be i nti mat ed and counsell ed in prior , so that they will have an opportunity to m ake necess ary arrangem ents. The surgeons will also get a chance to schedul e the t eam and tim e of surgery appropri at ely. The part ici pants of the study who are predi ct ed t o have hi gh risk are scheduled for an ext en ded hospit al st ay and int ensive care post -operatively. Thus the hospit al
admi nist ration can also pl an t he admissi ons and predi ct t he vacancy of beds more effi ciently. This study was aim ed at analyzing the ut ility of such a predi ctive s core devel oped by J.S .R andhawa and A.K. Pujahari( 1 6 ), in accurat ely predict ing the int raoperat ive difficulti es encount ered during cas es of l aparoscopi c chol ecyst ectom y.
Keywords: Cholelithiasis, laparoscopic cholecystectomy, predictive factors, conversion rate, scoring system
METHO DOLOG Y
This is a prospective obs ervational study conducted i n the Departm ent of General Surgery, SRM M edi cal C oll ege and R es earch C ent re from M arch - 2019. To August - 2020. All pati ents over 18 years of age admit ted in our departm ent for laparoscopi c ch ol ecyst ect omy from March -2019 To August - 2020 were taken up for t he s tudy. Approval for t his study was obtained from the institut e hum an ethi cs committ ee. Informed cons ent was taken from all pati ent s prior to surgery. 97 pat ients wi th di agnosis of chol elith iasis were incl uded i n t he study.
HISTORY
Age, Sex, h/o previous hospitalization {abdominal surgeries / cholecystitis / pancreatitis}
CLINICAL
BMI, Abdominal scar (infraumbilical or supraumbilical), palpable gall bladder
IMAGING
Gall bladder wall thickness, pericholecystic collection, impacted stone.
Each of t he pre operative predictive fact ors was assi gned an indivi dual score, as given in Table 1. The sums of the indi vidual s cores were com put ed, based on whi ch the cases were predi ct ed to be easy, diffi cult or very di fficult, as given bel ow.
TOTAL SCORE :
GRADING : EASY (<5) / DIFFICULT (6-10) / VERY DIFFICULT (11-15) (Randhawa JS, Pujahari AK. Indian J Surg 2009;71:198-201)
After the pre operative evaluation and anaesthetic assessment, the patients were subjected to Laparoscopic cholecystectomy
All the cases were operated on by a single surgeon and his team, using CO2
pneumoperitoneum at 12 mm Hg pressure, and two 10 mm and two 5 mm ports
The time taken for surgery was noted from the first port site incision to the closure of the last port
Following surgery, these parameters were noted :
✓ Operative Time taken from incision to port closure
✓ Biliary/ stone spillage
✓ Bleeding during surgery
✓ Injury to duct / artery
✓ Need for conversion regarding upon the difficulty of the case Easy:
✓ time taken <60 min
✓ with no bile spillage/ injury to duct or artery
Difficult:
✓ time taken 60–120 min
✓ with bile or stone spillage/ injury to duct
✓ but required no conversion Very difficult:
✓ time taken >120 min
✓ required conversion RESULTS
Statistical analysis employed included ‘mean’, ‘standard deviation’, ‘chi square tests’ and ‘t tests’ to compare the outcomes of the various parameters in both groups. In thi s study, m ajority of pati ents (62.9% pati ents) belonged to age group of ≤ 50 years and 37.1% were > 50 year s. Statistical analysis reveal ed a si gni fi cant correlat ion bet ween advanced age and intraoperati ve diffi culty (p value 0.003). In t his st udy, majorit y of the pati ents were fem al es (60.8%). Out of the 38 m al e s ubj ects, 5 of them were predi cted to be di ffi cult , and 1 was predict ed t o be ve ry di ffi cult, which were accurat e, but there was no signi fi cant correl ati on between m al e sex and int raoperative difficulty (p value 0.631). In t he pres ent study, onl y 7 pati ent s (7.2%) had a history of hospi tali zation for acut e chol ecystit is in the past , o f whi ch the i nt ra operative diffi culty 4 were very di ffi cult and 3 were di ffi cult, as i ntra operati ve bil e spill age caus ed the s urgery to t ake longer tim e than expect ed. The correl ation bet ween hi story of hospit ali zation and intra operative diffi cul ty was found to be significant (p value 0.001). this study, 53 patients had a BMI ≥ 25, of which only 11 patients were encount ered wit h diffi culty duri ng s urgery. There was no s igni fi cant correl ation bet ween B MI and i ntra operative di ffi culty (p val ue 0.114). In thi s study, out of 35 pati ent s (36.1%) wi th hi st ory of previous abdominal surgery, 6 cas es were di fficult and 4 were very diffi cult . Out of 86 cases predi cted to be easy, 83 were easy and 3 were diffi cult . Out of 8 cas es predi ct ed t o be di fficult, 7 were d iffi cult and one t urned out to be very di fficult.
All 3 cas es predi ct ed to be very di ffi cult were in fact, very di ffi cul t as predi ct ed. In t his st udy, the s cori ng system accurat ely predi ct ed the diffi cult y of s urgery in 93 out of 97 (95.8%) cases (Fi g.1)with a s ensiti vity of 96.51%
and specifi cit y of 100 %. Out of all t he pre operative fact ors considered for the scoring sys tem , history of previous abdomi nal surgery(r -0.522, p-0-001), history of previous hospi tal admissi on for cholecystitis (r -0.759, p -0.001), ultras onographic findings li ke presence of peri chol ecysti c col lection (r -0.646, p-0.001) and i ncreas ed GB wal l thi cknes s ( r-0.561, p -0.001) were found t o have a very high positi ve correl ation wit h di fficulty of surgery, whi le advanci ng age( r-0.301, p -0.003) had only a moderate positi ve correl ati on with intra operative di fficulty. BM I (r -0.162, p -0.114) and gender (r -0.05, p-0.631) did not affect t he i ntra operative di ffi culty si gni fi cantly i n this st udy. The above m enti oned findings are summ ari sed in tab les 2 -4.
LIMITATIONS OF STUDY
The challenges faced during performance of laparoscopic cholecystectomy are constantly evolving, so there is no fool proof method of accurately predicting the intra operative difficulty.
However, with the scoring system proposed in this study, the surgical team can be better prepared for newer methods like use of indocyanin green for better intra operative mapping of biliary tract, which makes the surgery much safer.
CONCLUS ION
This st udy was aim ed at as sessing t he utility of a pre operative predi ctive scoring sys tem devel oped by J .S.R andhawa and A.K.Puj ahari , i n predi cti ng the intra operative di ffi culty of l aparoscopi c cholecystect omy. The pre operative risk factors t aken int o account i ncl uded advancing age, m al e gender, previous history of hospitalis ation, obesity/ overwei ght , hist ory of previ ous s urgery to abdom en, pal pabl e GB on examinati on and USG findings li ke increas ed GB wal l t hi ckness , pres ence of perichol ecystic fluid coll ection an d impact ed stones were consi dered as the rel evant ri sk factors in the current st udy. It was concl uded that t his pre operative predict ive s coring system was rel iable and useful i n predicting t he di fficulty of LC accurat ely. Out of all t he pre operati ve fact ors consi dered for the s cori ng s yst em, history of previous abdominal surgery, hist ory of previous hospi tal admi ssion for cholecystitis , ultras onographic findings like presence of peri chol ecysti c coll ecti on and increased GB wall thi ckness were found to hav e a very high positi ve correl ation wit h diffi cult y of surgery, whi le advancing age had only a m oderat e positi ve correl ati on with i ntra operative di fficulty. Therefore the clini cal decisi on making s hould be done aft er the proper eval uation of the above menti oned deci sive factors.
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chole: a s coring m et hod. Indi an J Surg. 2009;71:198 – 201 CHARTS AND TABLES
Table 1: Different pre operative predictive factors and individual scores
FACTORS SCORE
(MAX- 15)
AGE <50 (0) >50 (1) 1
SEX FEMALE(0) MALE(1) 1
H/O HOSPITALISATION NO(0) YES(4) 4
BMI <25 (0) 25-27.5 (1), >27.5(2) 2
ABDOMINAL SCAR NO (0) INFRAUMBILICAL(1)
SUPRAUMBILICAL(2) 2
PALPABLE GALL
BLADDER
NO (0) YES ((1) 1
GB THICKNESS THIN
(≤4mm) (0)
THICK(>4mm) (2) 2
PERICHOLECYSTIC COLLECTION
NO (0) YES (1) 1
IMPACTED STONE NO (0) YES (1) 1
Table 2: Patient characteristics
Frequency
Age <50 yrs 61
>50 yrs 36
Sex Female 59
Male 38
H/O Hospitalisation Yes 7
No 90
BMI wt (kg)/ht (mt2)
<25 44
25-27.5 37
>27.5 16
Abdominal scar
No 62
Infra-umbilical 31 Supra-umbilical 4
Palpable gallbladder Yes 0
No 97
GB Wall thickness Thin 83
Thick (>4mm) 14
Pericholecystic collection Yes 8
No 89
Impacted stone Yes 0
No 97
Table 3: Correlation between operation time grading and grading of total score
In 95.8% (n=93) of the patients, there was a correlation between the operation time grading and grading of total score.
Table 4: Correlation tests between various variables
Sl.No Variables r
P value (Significant at 0.05 level)
Significant
/ Not
significant
1 Age and Total Score 0.32 0.002 Significant
2 Age and Operation time in minutes 0.301 0.003 Significant
3 Sex and Total Score 0.276 0.007 Significant
4 Sex and Operation time in minutes 0.05 0.631 Not
Significant 5 Operation time in minutes and Total Score 0.844 0.001 Significant 6 Operation time in minutes and BMI Score 0.162 0.114 Not
Significant 7 Operation time in minutes and Abdominal
scar 0.522 0.001
Significant 8 Operation time in minutes and GB Wall
thickness 0.561 0.001
Significant 9 Operation time in minutes and Peri
cholycestic collection 0.646 0.001
Significant 10 Operation time in minutes and H/O
Hospitalisation 0.749 0.001
Significant 11 Total Score and BMI Score 0.495 0.001 Significant 12 Total Score and Abdominal scar 0.327 0.002 Significant 13 Total Score and GB Wall thickness 0.658 0.001 Significant 14 Total Score and Peri cholycestic collection 0.746 0.001 Significant 15 Total Score and H/O Hospitalisation 0.767 0.001 Significant
Easy Difficult Very Difficult
Easy 83 3 0
Difficult 0 7 1
Very Difficult 0 0 3
Operation time
T ot al Sc or e
Correlation between total
score and operation time
Figure 1: Correlation between grading using operative time taken and grading using preoperative predictive score
