PREOPERATIVE SCORING SYSTEM TO PREDICT DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY

Abstract

Laparoscopic Cholecystectomy is considered as the most common laparoscopic procedures in the world & is now the Gold standard treatment for Cholelithiasis & cholecystitis Gallstone disease (cholelithiasis) has increasingly become one of the major causes of abdominal pain & discomfort in the developing world. Its occurrence has been found to be high (7.4%) in the adult population in the cities of Chandigarh & New Delhi in North Indiawhich is one of the highest in the world.Gallstones are more common in the female population (61%) as compared to males (39%). The common age group affected is 45–60 years (38.5%) among females, & above 60 years in males (20.8%). A relatively higher prevalence of 39% among males when compared to reports from past studies indicates a significant shift in the pattern of prevalence of gallstone disease1. Many risk factors for cholelithiasis cannot be modifiable such as ethnic background, advancing age, female gender & family history or genetics. The modifiable risks for cholelithiasis are obesity, quick weight loss & a idle lifestyle. Rising epidemic of obesity & the metabolic syndrome predicts an escalation in gallstones . Frequent risk factors for biliary sludge includes pregnancy, drugs like ceftiaxone, octreotide& thiazide diuretics, total parenteral nutrition & fasting. Diseases like cirrhosis, chronic hemolysis& Crohn's disease are few risk factors for black pigment stones2. In our hospital setup (R L Jalappa Hospital & Research Center, Tamaka , Kolar , Karnataka) , in the Department of surgery , a total of 166 cholecystectomies were performed in the period between October 2015 to September 2018 . 134 of these cases were elective laparoscopic cholecystectomy & twenty five of them were elective open cholecystectomies. There were a total of 7 cases which had to be changed from laparoscopic to open procedure due to intra operative difficulty involved. That gives us a conversion rate of 4.96% over the past 3 years in our hospital setup. 11 Pre operative prediction for the likelihood of conversion to open or difficulty of operation is an important aspect of planning laparoscopic surgery as the prevalence of gall bladder disease is increasing in india & laparoscopic surgery is becoming more accesicible. Arogya Karnataka scheme , which can be used in our hospital setup ,has laparoscopic cholecystectomy as one of its schemes for impoverished patients bringing the chance of laparoscopic surgery to the public. As a result the number of laparoscopic cholecystectomies as a whole as well as the risk of conversion increases making the need for study all the more important. AIMS & OBJECTIVES 1. To validate that a scoring system based on history , physical examination & Ultrasonographic findings is a reliable predictor of difficulty of laparoscopic cholecystectomy. 2. To help in choosing a favourable treatment modality depending on the score. 3. To help predict the duration of hospital stay & post operative complications with the help of this system METHODS A Prospective & Comparative study, considering 70 patients admitted & undergoing laparoscopic cholesystectomy at R.L. Jalappa hospital & research center attached to Sri Devaraj Urs Academy of Higher Education Tamaka, Kolar, during the period of NOVEMBER 2018 & 10th OCTOBER 2020. 12 RESULTS The preoperative scoring system devised is excellent at predicting the intraoperative difficulties encountered by surgeons while performing laparoscopic cholecystectomy with a sensitivity of 88.9% & a specificity of 92.3%. The scoring system also predicted intraoperative complications with a specificity of 94.2% when score is >7. There was also a very strong correlation between the preop score & the duration of surgery (r=0.752, p<0.001) & also between the preoperative score & the duration of hospital stay (r=0.788, p<0.001) CONCLUSION Preoperative prediction of the risk of conversion or difficulty of operation is an important aspect of planning laparoscopic surgery. I would conclude that the scoring system evaluated in our study can be used to predict difficult cases.