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 Table of Contents     
Year : 2018  |  Volume : 14  |  Issue : 4  |  Page : 362-364

Inflammation and indication: A novel approach to predict degree of difficulty during emergency laparoscopic cholecystectomy

Department of Upper GI Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP, United Kingdom

Date of Submission07-Oct-2017
Date of Acceptance08-Oct-2017
Date of Web Publication3-Sep-2018

Correspondence Address:
Dr. Ravindra Sudhachandra Date
The University of Manchester, Manchester Academic Health Science Centre, Lancashire Teaching Hospital NHS Foundation Trust, Chorley PR7 1PP
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_197_17

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How to cite this article:
Date RS, Gerrard AD. Inflammation and indication: A novel approach to predict degree of difficulty during emergency laparoscopic cholecystectomy. J Min Access Surg 2018;14:362-4

How to cite this URL:
Date RS, Gerrard AD. Inflammation and indication: A novel approach to predict degree of difficulty during emergency laparoscopic cholecystectomy. J Min Access Surg [serial online] 2018 [cited 2021 Oct 17];14:362-4. Available from:

The indications for laparoscopic cholecystectomy (LC), unlike many other organs, range from intrinsic pathologies of the gallbladder like biliary colic to the extrinsic ones like stones in common bile duct (CBD) or gallstone pancreatitis. The operation itself can be ‘very easy’ or ‘extremely difficult’ requiring conversion to an open procedure.

Some studies have reported C-reactive protein (CRP) as a useful adjunct to other factors to improve the prediction of conversion of LC.[1],[2] In 2016, after multivariate analysis, we proposed peak CRP value of >220 during acute admission as a single strong predictor of conversion of LC.[3] This finding is also supported by other recent studies.[4],[5] We prefer to use the term ‘predicting the degree of difficulty (DoD)’ rather than ‘predicting conversion,’ as many difficult cholecystectomies can be completed laparoscopically by experienced surgeons.

Raw data from our previous study suggested correlation between indication of an operation and conversion. For example, LC for gallstone pancreatitis, unlike that for acute cholecystitis, is an ‘easy’ operation with virtually no need for conversion. These data also suggested that in patients with gallbladder pathology, the DoD increases with the rise of CRP. This difficulty culminated in conversion in 61.9% patients when CRP value crossed 220. Retrospective nature of this study precluded accurate correlation of degree of difficulty with a rising CRP. Therefore, a prospective data collection was commenced locally with the aim to:

  1. Validate CRP as a single predicative factor for predicting DoD of LC when the operation is indicated for intrinsic gallbladder pathology
  2. Examine the effect of rising CRP on DoD
  3. Create a pathway based on indication and CRP to predict difficult LC.

Data were collected prospectively from April 2016 to July 2017 for all consecutive acute hospital admissions with gallstone-related diseases. Patients were included if they were over the age of 18 years, if LC was clinically indicated (either urgently or at later date) and if they were fit for an operation. Operations were performed either during index admission, semi-electively on the next available list or as delayed LC. Once included, patients were grouped based on their reason for admission: Group 1 – gallbladder disease (cholecystitis, biliary colic); Group 2 – CBD stones; Group 3 – gallstone pancreatitis.

Data were collected for demographics, peak CRP level during acute admission, indication for operation, timing of operation, length of operation, and the DoD (1–4, 4 being most difficult) using Nassar scoring system.[6]

Categorical data were compared using Chi-square test and continuous data (e.g., duration of operation) using t-test. Multivariate analysis to compare CRP with other predictive factors was not performed as it is already done in our previous study.[3]

During the study period, 163 patients (110 females, 53 males, average age 52.7 years) underwent LC. One patient from Group 1, with CRP <220, had type 1 Mirizzi's syndrome leading to CBD injury.

The number of patients in each group and proportion of them having DoD 4 are shown in [Figure 1]. Occurrence of DoD 4 in Group 1 patients was 79.3% when CRP was >220, as compared to 20.1% when CRP was <220 (P < 0.05). Conversion rates for the same groups were 51.7% and 11.7% (P < 0.05), respectively. Overall conversion rate in Group 1 was 22.64% (24/106) which is comparable to 22% in delayed and 19.7% in early intervention group in Cochrane review.[7] Similar trends were noticed in Group 2 but not Group 3. In Group 1, the average operating time was significantly longer in those with CRP >220 (117 vs 88 min). The effect of rising CRP on increasing DoD for Group 1 patients is shown in [Figure 2] (R2 = 0.41353).
Figure 1: Indication of cholecystectomy and degree of difficulty

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Figure 2: Increase in degree of difficulty with rise in peak C-reactive protein

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Previous literature used various factors such as body mass index and previous surgery for predicting conversion of LC. DoD in Nassar classification refers to difficulty in dissecting Calot's triangle only. In our opinion, this is the only clinically relevant difficulty that needs to be predicted preoperatively to prevent CBD injury.

A recent population-based study highlights high incidence of CBD injury rates in those converted (2%), compared to those completed laparoscopically (0.3%).[8] Strasberg's critical view of safety[9] is difficult to demonstrate in the first group of patients when CRP is >220 and preoperative prediction of DoD remains challenging. We feel that our simple ‘indication and inflammation’-based prediction would help experienced surgeons to get involved in both decision-making process and performing operations in this group of patients to reduce the complication rate.[10]

We acknowledge the limitation of smaller numbers in our study. However, the trends shown in this as well as our previous study support the significant role of ‘indication and inflammation’ in predicting difficult LC. A large multicentre study will be needed to prove its real value in reducing CBD injuries.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Schäfer M, Krähenbühl L, Büchler MW. Predictive factors for the type of surgery in acute cholecystitis. Am J Surg 2001;182:291-7.  Back to cited text no. 1
Teckchandani N, Garg PK, Hadke NS, Jain SK, Kant R, Mandal AK, et al. Predictive factors for successful early laparoscopic cholecystectomy in acute cholecystitis: A prospective study. Int J Surg 2010;8:623-7.  Back to cited text no. 2
Jessica Mok KW, Goh YL, Howell LE, Date RS. Is C-reactive protein the single most useful predictor of difficult laparoscopic cholecystectomy or its conversion? A pilot study. J Minim Access Surg 2016;12:26-32.  Back to cited text no. 3
Wevers KP, van Westreenen HL, Patijn GA. Laparoscopic cholecystectomy in acute cholecystitis: C-reactive protein level combined with age predicts conversion. Surg Laparosc Endosc Percutan Tech 2013;23:163-6.  Back to cited text no. 4
Kabul Gurbulak E, Gurbulak B, Akgun IE, Duzkoylu Y, Battal M, Fevzi Celayir M, et al. Prediction of the grade of acute cholecystitis by plasma level of C-reactive protein. Iran Red Crescent Med J 2015;17:e28091.  Back to cited text no. 5
Nassar AH, Ashkar KA, Mohamed AY, Hafiz AA. Is laparoscopic cholecystectomy possible without video technology? Minim Invasive Ther Allied Technol 1995;4:63-5.  Back to cited text no. 6
Gurusamy KS, Samraj K. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Cochrane Database Syst Rev. 2006; 18(4):CD005440.  Back to cited text no. 7
Sutcliffe RP, Hollyman M, Hodson J. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective U.K. database of 8820 patients. HPB (Oxford) 2016;18:922-8.  Back to cited text no. 8
Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 2002;9:543-7.  Back to cited text no. 9
Giger UF, Michel JM, Opitz I. Risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy: Analysis of 22,953 consecutive cases from the Swiss Association of Laparoscopic and Thoracoscopic Surgery database. J Am Coll Surg 2006;203:723-8.  Back to cited text no. 10


  [Figure 1], [Figure 2]


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2004 Journal of Minimal Access Surgery
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