Prediction of Difficult Laparoscopic Cholecystectomy Based on Ultrasonographic Findings

Abstract

Laparoscopic cholecystectomy (LC) represents the best treatment in symptomatic cholelithiasis with better results than open surgery, in terms of recovery time, postoperative pain, and hospitalization. Nevertheless, some large proportion of LC operations 10 percent to 30 percent in the world are termed technically challenging owing to intense inflammation, thick adhesions, or atypical anatomy. These instances have been linked with increased number of intraoperative complications especially the injury of the bile duct that has remained one of the gravest and most expensive surgical events in general surgery. In low-resource practice like in Iraq, where advanced imaging (e.g., MRCP), intraoperative cholangiography and specialized hepatobiliary surgeons are scarce, predicting preoperative surgical difficulty has become not only clinically useful, but even a patient-saving and resource-conserving tool. The purpose of the research is to determine the predictive capacity of routinely available ultrasonographic results in the determination of the high-risk patients facing a difficult laparoscopic cholecystectomy in Al-Zahraa Teaching Hospital, Wasit Province, Iraq. We also suggest a non-complicated and evidence-based ultrasound scoring system, which can be applied in everyday clinical practice in similar environments with limited resources.180 adult patients who undergo LC between January 2023 and December 2024 were used as prospective subjects of the observational study. Certified radiologists conducted preoperative abdominal ultrasound, including the evaluation of such parameters as the gallbladder wall thickness, the presence of pericholecystic fluid, stone impaction, and cystic duct visibility as well as gallbladder distension. The Nassar scale (Grades I III IV) was validated as an intraoperative tool to determine surgical difficulty, whereby Grades III and IV were considered difficult procedures. Independent predictors were identified by means of univariate and multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve analysis was used to examine the diagnostic capability of a composite ultrasound score. One hundred and seventy cases (170) could be analyzed but 42 of them (24.7) were defined as difficult LC. Multivariate analysis helped to identify independent predictors, such as the gallbladder wall being thicker than 4 mm (adjusted OR = 4.2; 95% CI: 1.9 911.7; p = 0.001), presence of impacted stones (OR = 3.8; 95% CI: 1.78.5; p = 0.002), and absence of visualization of the cystic duct on ultrasound (OR = 5.1; 95 A three-variable predictive regression model had area under the ROC curve( AU C) 0.89, sensitivity 86% and specificity 81% at a cut off score of 2 or more. Preoperative ultrasonography which is a relatively cheap and widely available modality in hospitals in Iraq can be useful in predicting challenging laparoscopic cholecystectomy. The suggested ultrasound-based scoring system is a viable solution in terms of risk stratification, allowing to plan the surgery better, to counsel the patient better, and to be safer, especially in provincial healthcare facilities such as Al-Zahraa Teaching Hospital where the presence of advanced backup resources can be restricted.