Essential strategies for the management of challenging laparoscopic cholecystectomy procedures

Table 1 Preoperative risk factors for difficult laparoscopic cholecystectomy

n	Factor
1	Obesity
2	Cirrhosis
3	Fatty liver infiltration
4	Elevated American Society of Anesthesiologists score
5	Diabetes mellitus
6	Previous upper abdominal surgery
7	In acute cholecystitis, diabetes mellitus, positive Murphy’s sign
8	Previous acute cholecystitis or percutaneous gallbladder drainage
9	Concomitant common bile duct stones
10	Thickened gallbladder wall in imaging
11	Pericholecystic fluid collection in imaging
12	Impacted gallstone in gallbladder neck in imaging
13	Previous episode of acute biliary pancreatitis
14	C- reactive protein levels > 11 mg/dL in elective procedures

Table 2 Conditions that required conversion from laparoscopic to open cholecystectomy

n	Condition
1	Severe fibrosis
2	Hard scar
3	Uncontrolled hemorrhage
4	Cholecystoenteric fistula
5	Mirizzi syndrome
6	Surgeon’s expertise
7	Suspected malignancy

Table 3 Randhawa and Pujahari[96] difficulty scoring system for laparoscopic cholecystectomy

Factors	Score1
Age > 50 years	1
Male gender	1
History of acute cholecystitis	4
BMI > 27.5	1
Abdominal scar	1
Palpable gallbladder	1
GB wall thickness > 4 mm	2
Pericholecystic collection	1
Impacted stone	1

¹Grading: Easy 0-5, difficult 6-10, very difficult >10.

BMI: Body mass index; GB: Gallbladder.

Table 4 Sugrue et al[97] difficulty scoring system for laparoscopic cholecystectomy

Factors	Score1
Adhesions covering gallbladder	1-3
Distended or contracted gallbladder	1
Unable to grasp gallbladder	1
Stone ≥ 1 cm impacted in Hartmann’s pouch	1
BMI > 30	1
Time to identify cystic artery/duct > 90 minutes	1
Severe inflammation, necrosis, perforation	1

¹Grading: Easy 0-1, moderate 2-4, difficult 5-7, extreme 8-10.

BMI: Body mass index.

Table 5 Nassar et al[98] difficulty grading system for laparoscopic cholecystectomy

Grade	Factors
I	Floppy GB, clear anatomy
II	Mild adhesions
III	Dense adhesions, difficult dissection
IV	Severe inflammation, empyema, contracted gallbladder
V	Mirizzi syndrome, cholecystoenteric fistula

GB: Gallbladder.

Table 6 Simplified management algorithm for laparoscopic cholecystectomy

Order	Steps
1	Preoperative clinical, biochemical and imaging assessment
2	Initiation of laparoscopic cholecystectomy
3	Intraoperative imaging utilization if needed
4	Achieving CVS can lead to completion of uneventful procedure
5	Impossible CVS necessitates bailout policy (subtotal laparoscopic cholecystectomy as first choice)
6	Unclear anatomy, persistent bleeding, potential CBD injury at any stage, or suspected malignancy necessitate immediate conversion to open cholecystectomy

CVS: Critical view of safety; CBD: Common bile duct injury.