European Journal of Cardiovascular Medicine

Laparoscopic cholecystectomy (LC) has emerged as the gold standard for the surgical management of symptomatic gallstone disease and cholecystitis, offering advantages such as reduced postoperative pain, shorter hospital stays, and faster recovery times when compared to open cholecystectomy (OC)[1],[2]. Despite these benefits, the procedure is not without challenges, notably the risk of conversion from laparoscopic to open surgery due to various intraoperative difficulties[3]. The decision to convert is multifactorial, influenced by factors such as the severity of inflammation, anatomical variations, and the presence of complications like gallbladder perforation or injury to the biliary tree[4]. Therefore, a reliable and standardized method for grading the operative findings at LC could provide significant benefits in predicting the likelihood of conversion, enhancing surgical planning, and improving patient outcomes.

The complexity of operative findings in laparoscopic cholecystectomy varies widely, ranging from mild, chronic cholecystitis to acute, gangrenous forms of the disease, each presenting its unique set of challenges[5]. Historically, the assessment of these findings has been subjective, with significant variability in reporting and decision-making among surgeons[6]. This lack of standardization complicates the ability to accurately predict surgical outcomes, including the risk of conversion to OC and postoperative complications. Furthermore, the absence of a universally accepted grading systemhampers the comparison of surgical data across studies and institutions, limiting the advancement of surgical techniques and patient care protocols[7].

Recognizing these challenges, the present study aims to develop and validate a new scoring system for grading operative findings at laparoscopic cholecystectomy. This system seeks to quantify the severity of cholecystitis observed during surgery, providing a standardized method for assessing operative difficulties. The objectives of this study are twofold: firstly, to establish a scoring system that accurately reflects the complexity of operative findings, facilitating a more standardized approach to reporting and decision-making in laparoscopic cholecystectomy; and secondly, to evaluate the utility of this scoring system in predicting the need for conversion to open cholecystectomy, thereby enhancing preoperative planning and patient counseling.

The proposed scoring system is based on a comprehensive review of the literature, identifying key factors that influence operative difficulty and the likelihood of conversion. These factors include the degree of gallbladder inflammation, the presence of adhesions, gallbladder wall thickness, and the visibility of critical anatomical landmarks[8],[9]. By grading these elements, the scoring system aims to provide a quantitative measure of operative complexity, offering a predictive tool for surgeons to assess the risk of conversion and potentially reduce the incidence of intraoperative complications.

To validate the proposed scoring system, a prospective study will be conducted, applying the scoring system to a cohort of patients undergoing laparoscopic cholecystectomy. The outcomes of this study will include the accuracy of the scoring system in predicting conversion to open surgery, its correlation with operative time, and its association with postoperative complications. Through this rigorous evaluation, the study aims to demonstrate the clinical utility of the scoring system, supporting its adoption as a standard tool in the preoperative assessment for laparoscopic cholecystectomy.

The development of a standardized scoring system for operative findings at laparoscopic cholecystectomy represents a significant advance in the field of minimally invasive surgery. By providing a quantitative method for grading the severity of cholecystitis, this system has the potential to improve surgical planning, enhance patient safety, and facilitate the comparison of surgical outcomes across different settings. Ultimately, the adoption of such a system could lead to better surgical decision-making, reduced rates of conversion to open cholecystectomy, and improved patient outcomes in the management of gallstone disease.

Aims and Objectives

The primary aim of the study was to meticulously analyze the efficacy of a novel scoring system designed for the operative findings observed during laparoscopic cholecystectomy procedures. This scoring system sought to standardize the grading of cholecystitis by categorizing the severity of operative findings, thereby facilitating a more systematic approach to predicting the need for conversion from laparoscopic to open cholecystectomy. The general objective was to scrutinize this scoring system to standardize the degree of cholecystitis observed during surgery, while the specific objective focused on utilizing this system to anticipate the likelihood of converting laparoscopic procedures to open surgery.

The methodology adopted for this study was a descriptive cross-sectional approach, grounded in a hospital-based setting. This research was carried out in the rural environment of the Bankura Sammilani Medical College and Hospital, within the Department of General Surgery. The timeline spanned approximately one and a half years, commencing in March 2019 and concluding in August 2020. The preparatory phase of the study lasted one month, followed by a twelve-month period dedicated to data collection. Subsequently, four months were allocated for data entry and analysis, with the final month reserved for report writing. The study population comprised patients of either sex, admitted to the surgery ward of Bankura Sammilani Medical College and Hospital, who met the study's inclusion criteria.

The sample size was determined using a formula suitable for evaluating diagnostic methods. Based on a 95% confidence interval and an anticipated prevalence/incidence rate of 50% for the target disease, alongside an acceptable error margin of 10%, the initial sample size calculated was 96. To account for potential non-responders, an additional 10% was added, resulting in a final sample size of 106 patients. The sampling design was structured around the admission rate of 6-7 patients per week into the General Surgery Department of BSMCH, with data collection occurring twice weekly. Days for data collection were chosen randomly each week using the lottery method, and eligible cases were selected through simple random sampling (lottery method), continuing until the desired sample size was reached.

Inclusion criteria encompassed all patients diagnosed with cholelithiasis, aged over 20 years, who were scheduled to undergo laparoscopic cholecystectomy. Exclusion criteria were designed to omit patients presenting with acute cholecystitis, those undergoing laparoscopic cholecystectomy in conjunction with other laparoscopic interventions, procedures involving common bile duct exploration, and patients with contraindications to laparoscopic surgery such as cardiovascular or pulmonary disease, coagulopathies, and end-stage liver disease.

The study's parameters revolved around a detailed descriptive analysis of patients admitted to BSMCH for laparoscopic cholecystectomy. A proposed scoring system, ranging from 1 to 10, was employed to gauge the severity of cholecystitis and the potential difficulty of the surgery based on operative findings. These included the appearance of the gallbladder, the extent of adhesions, distension or contraction of the gallbladder, ease of access, presence of local/septic complications, and the time taken to identify the cystic artery and duct. Scores were allocated to quantify the ease or difficulty of the procedure, with categories ranging from mild to extreme based on the total score obtained.

Data collection and interpretation were conducted following the approval from the Institutional Ethics Committee and The West Bengal University of Health Sciences. Ethical clearance was secured, and informed consent was obtained from all participants in their vernacular language, ensuring comprehension of the study's procedures. The statistical analysis was performed using SPSS (version 27.0) and GraphPad Prism version 5, with data summarized as mean and standard deviation for numerical variables, and count and percentages for categorical variables. Statistical significance was determined using two-sample t-tests, paired t-tests, chi-squared tests, and Fisher's exact test as appropriate, with a p-value ≤ 0.05 indicating statistical significance.