title: Pre-operative Prediction of Difficult Laparoscopic Cholecystectomy.
abstract: BACKGROUND
  Laparoscopic cholecystectomy is one of the most common operation performed. Though LC have become safer and easier at times it can be difficult. Difficult cases can result in prolonged operative time, bleeding, bile spillage, conversion to open technique and bile duct injury resulting in unplanned prolonged hospital stay, increase in estimated cost to the patients and for the surgeon it leads to increased stress during operation and time pressure to complete the operative list. . Identification of difficult cases has potential advantages for surgeons, patients and their relatives. We aim to develop and validate a scoring system to predict difficult LC preoperatively.
  
  
  METHODS
  Prospective study. History, physical examination, abdominal ultrasound and biochemical parameters were included to develop a scoring system. Hundred patients undergoing LC were included and preoperative scores were calculated preoperatively to predict difficult LC which was compared with operative assessment.
  
  
  RESULTS
  Sensitivity and specificity of the preoperative scoring for difficult case was 53.8 % and 89.2 % respectively with PPV of 63.64 % and NPV of 84.62%. Only three parameters (history of acute cholecystitis, gall bladder wall thickness and contracted gall bladder) were statistically significant to predict difficult LC individually. Area under ROC curve was 0.779 (95 % CI, 0.657-0.883).
  
  
  CONCLUSIONS
  Preoperative scoring system can be used to predict difficult LC. Surgeons can plan operation based on predicted difficulty. Patients and relatives can be counselled preoperatively for the possibility of difficult operation, prolonged hospital stay and increased cost in predicted difficult case.
authors.affiliation: Department of Surgery, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal.
authors.forename: M R
authors.initials: MR
authors.lastname: Joshi
authors.affiliation: Department of Surgery, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal.
authors.forename: T P
authors.initials: TP
authors.lastname: Bohara
authors.affiliation: Department of Surgery, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal.
authors.forename: S
authors.initials: S
authors.lastname: Rupakheti
authors.affiliation: Department of Surgery, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal.
authors.forename: A
authors.initials: A
authors.lastname: Parajuli
authors.affiliation: Department of Surgery, Lumbini Medical College and Teaching Hospital, Palpa, Nepal.
authors.forename: D K
authors.initials: DK
authors.lastname: Shrestha
authors.affiliation: Department of Surgery, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal.
authors.forename: D
authors.initials: D
authors.lastname: Karki
authors.affiliation: Department of Surgery, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal.
authors.forename: U
authors.initials: U
authors.lastname: Laudari
keywords: Difficult cholecystectomy; Laparoscopic cholecystectomy; Symptomatic cholelithiasis.