Cholelithiasis is one of the most prevalent biliary tract diseases worldwide and remains a common indication for surgical intervention. Laparoscopic cholecystectomy (LC), first introduced in the late 1980s, has now become the gold standard for treating symptomatic gallstone disease due to its minimally invasive nature, shorter hospital stay, faster recovery, and reduced postoperative pain compared with open surgery [1,2]. Despite these advantages, a subset of patients present with “difficult laparoscopic cholecystectomy” (DLC), which is associated with increased operative time, higher conversion rates to open cholecystectomy, and increased risk of complications [3,4].

Predicting the difficulty of LC preoperatively or early intraoperatively is crucial for surgical planning, patient counseling, and reducing morbidity. Several factors have been implicated in increasing operative difficulty, including demographic variables (age, male sex, obesity), clinical presentation (recurrent attacks of cholecystitis, prior hospitalizations), sonological features (gallbladder wall thickening, pericholecystic collection, impacted stones), and intraoperative findings (dense adhesions, altered Calot’s anatomy) [5–7]. Ultrasonography (USG), being cost- effective and widely available, provides valuable insights into gallbladder pathology, while intraoperative findings remain the definitive determinant of surgical complexity [8].

Conversion to open cholecystectomy, though less common today, is still required in difficult cases to ensure patient safety. Reported conversion rates vary from 2% to 15%, depending on patient characteristics and institutional experience [9]. Recognizing predictors of difficulty in LC not only allows better preparedness for the surgical team but also helps in timely decision- making regarding conversion, thereby reducing operative complications such as bile duct injury, The present study was designed to identify and evaluate the clinical, sonological, and Intraoperative predictors of difficult laparoscopic cholecystectomy in patients undergoing surgery for cholelithiasis. By analyzing these predictors systematically, the study aims to improve preoperative risk stratification and optimize surgical outcomes.

MATERIALS AND METHODS

Study Design and Setting:

This was a prospective cross-sectional observational study conducted in the Department of General Surgery, RNT Medical College and MB Hospital, Udaipur, Rajasthan. The study was carried out after obtaining approval from the Institutional Ethical Committee and written informed consent from all participants.

Study Population and Duration:

All consecutive patients admitted with a diagnosis of cholelithiasis and scheduled for laparoscopic cholecystectomy between February 2024 and July 2025 were considered for inclusion.

Sample Size:

A sample size of 148 patients was calculated using the formula for estimating a single proportion:

Assumption: variable must be categorical.

Formula: n= (Z1-α/2)2 (100-P) P/d2

Where (Z1-α/2) =1.96 (2 tailed and 5% α error)

P= proportion of difficult Laparoscopic Cholecystectomy having CRP value >22mg/L= 78%

(In previous study by Kaushik B et al. Int. Surg J 2018) d= Relative precision 10% of 78%

Inclusion Criteria

• All patients clinically, serologically, and radiologically diagnosed with calculus cholecystitis (cholelithiasis).
• Patients willing to undergo laparoscopic

Exclusion Criteria

• Acute
• Acute
• Acute
• Other systemic inflammatory conditions (e.g., inflammatory bowel disease).

Data Collection:

A detailed clinical history and physical examination were performed for all patients. Demographic data (age, sex), symptoms (pain abdomen, vomiting, dyspepsia, nausea), and previous hospitalizations were recorded. Preoperative blood samples were taken for routine laboratory tests, including liver function tests and serum C-reactive protein (CRP) levels. Radiological evaluation was done using ultrasonography (USG) and, when indicated, magnetic resonance cholangiopancreatography (MRCP).

Sonological Parameters Assessed

• Gallbladder wall thickness (>4 mm considered significant).
• Presence of pericholecystic fluid
• Impacted gallstones at the neck or cystic

Surgical Procedure and Intraoperative Assessment

All laparoscopic cholecystectomies were performed by consultants with at least three years of laparoscopic experience, or by residents under direct supervision. Operative findings including gallbladder appearance (distended, inflamed, contracted), presence of adhesions, bile/stone spillage, and duct/artery injury were documented.

Definition of Difficult Laparoscopic Cholecystectomy

• Operative time >60 minutes, and/or
• Significant bleeding, dense adhesions, difficult dissection of Calot’s triangle, or need for conversion to open cholecystectomy.

Data Recording:

Preoperative risk scoring was done using standardized criteria based on clinical and sonological findings. Patients were categorized into easy, difficult, or very difficult LC groups.

Statistical Analysis:

Data were entered in Microsoft Excel 2010 and analyzed using SPSS version 16. Results were expressed as mean ± standard deviation (SD) for continuous variables and as percentages for categorical variables. The chi-square test was applied for categorical data, and Student’s t-test for continuous data. A p-value <0.05 was considered statistically significant.

RESULT

Demographic profile of study population

A total of 148 patients with cholelithiasis were included. The mean age was 45.5 years, with most patients in the 41–50 year age group (27.7%). Females predominated, accounting for 75% of cases (female-to-male ratio = 3:1).

Table 1: Demographic profile of study population (n = 148)

The most common presenting complaint was abdominal pain (60%), followed by vomiting (36%) and dyspepsia (31%). Shown in fig 1.

Fig1: Symptoms of patients with cholelithiasis

Serum CRP levels varied widely. More than half of patients (53.37%) had CRP <22 mg/dl, while 43.24% had CRP 22–83 mg/dl, and only 3.37% had CRP >83 mg/dl which is represent in table 2.

Table 2: CRP values among study population

On ultrasonography, pericholecystic collection was the most frequent finding (31.75%), followed by gallbladder wall thickening >4 mm (24.32%) and impacted stones (10.13%). Shown in fig 2.

Fig2: USG findings among study population

Operative Findings and Outcomes:

Intraoperative assessment showed that abnormal gallbladder appearance was the most common finding (65 cases), followed by pericholecystic adhesions (37 cases). Bile/stone spillage and duct/artery injury were rare (3 cases each).

Table 3: Intraoperative findings

Regarding gallbladder appearance, 56.08% were normal and distended, 25% were distended and inflamed, and 18.91% were contracted. Which is shown in table 4.

Table 4: Gallbladder appearance intraoperatively

The mean operative time increased with the difficulty of surgery. Simple LC averaged 30.68 minutes, difficult LC 54.7 minutes, and conversion to open 84.28 minutes.

Table 5: Duration of surgery

Preoperative scoring classified 76.35% of cases as easy, 22.9% as difficult, and only 0.013% as very difficult.

Table 6: Preoperative scoring

Overall, 73.64% of patients underwent simple cholecystectomy, 21.63% had difficult cholecystectomy, and 4.73% required conversion to open surgery. Shown in fig 3

Fig 3: Type of operation

DISCUSSION

Laparoscopic cholecystectomy (LC) has become the gold standard treatment for symptomatic cholelithiasis, but a significant subset of patients continue to pose intraoperative challenges, often necessitating conversion to open surgery. In our study, 21.6% of patients underwent difficult LC and 4.7% required conversion to open, findings consistent with earlier reports that place conversion rates between 2% and 15% worldwide [11,12]. Identifying predictors of difficult LC remains essential for operative planning, improving patient safety, and reducing morbidity.

In the present series, female patients predominated (75%), reflecting the well-documented higher prevalence of gallstone disease in women due to hormonal and metabolic influences [13]. However, the presence of male sex has often been associated with more severe inflammation and a higher likelihood of difficult LC in other studies [14]. Our findings showed no significant correlation between gender and operative difficulty, suggesting that inflammatory changes and gallbladder pathology may outweigh gender differences in predicting surgical complexity.

Age has also been reported as a risk factor for difficult LC, with older patients often presenting with chronic inflammation, fibrosis, and adhesions [15]. In our study, the mean age was 45.5 years, and the highest proportion of difficult cases occurred in the 41–50 year group. While age itself was not a statistically significant predictor, our data support previous observations that patients with a longer history of gallstone disease tend to demonstrate greater operative difficulty.

Serum CRP levels showed a strong correlation with operative outcomes in our study. The mean CRP was 22 mg/dl in simple cases, 46 mg/dl in difficult cases, and 83 mg/dl in those converted to open surgery, with statistical significance (p <0.0003). These findings align with the work of Kaushik et al., who demonstrated significantly higher CRP levels in difficult and converted cases [16]. Similarly, Mok et al. reported that CRP values >200 mg/dl had strong predictive value for gangrenous cholecystitis and operative difficulty [17]. The role of CRP as a cost-effective and reliable biochemical marker is thus reinforced by our study.

Sonological findings were also important predictors. Gallbladder wall thickening (>4 mm) and pericholecystic collection were observed in 24.3% and 31.7% of cases, respectively, and were significantly associated with intraoperative difficulty. These results are comparable with studies by Randhawa et al. and Agrawal et al., who emphasized the predictive value of USG findings in preoperative scoring systems [18,19]. Impacted stones at the neck or cystic duct, present in 10.1% of our patients, also contributed to distorted anatomy and prolonged operative time, corroborating earlier observations that impacted stones complicate dissection of Calot’s triangle [20].

Intraoperatively, the most common challenges encountered were abnormal gallbladder appearance and adhesions, both of which significantly prolonged operative time. In our cohort, difficult LC averaged 54.7 minutes, nearly double the mean operative time of simple cases (30.6 minutes). Similar trends have been described in previous studies, where adhesions and fibrosis were among the strongest intraoperative predictors of conversion [21]. The presence of bile/stone spillage and ductal/arterial injury was low in our study (2%), reflecting the importance of surgeon experience and careful dissection in minimizing complications.

Our findings reaffirm the multifactorial nature of difficult LC. No single parameter can reliably predict difficulty, but a combination of clinical features, sonological parameters, and CRP levels provides a practical risk stratification strategy. Importantly, preoperative scoring based on these parameters in our study correctly anticipated difficulty in over 22% of cases, reinforcing the utility of such systems in surgical practice.

CONCLUSION

Laparoscopic cholecystectomy remains the gold standard for treating symptomatic cholelithiasis, yet a considerable proportion of cases are difficult and may require conversion to open surgery. In this prospective study, serum CRP levels, ultrasonographic findings (gallbladder wall thickening, pericholecystic collection, impacted stones), and intraoperative features (adhesions, abnormal gallbladder appearance) were found to be reliable predictors of surgical difficulty.

Preoperative risk assessment using a combination of clinical, biochemical, and imaging parameters allows better surgical planning, timely anticipation of technical challenges, and safer operative outcomes. Early recognition of high-risk patients may help in reducing operative time, minimizing complications, and guiding appropriate decision-making regarding conversion.

Our findings support the integration of these predictors into routine preoperative evaluation to optimize patient care and improve surgical outcomes in laparoscopic cholecystectomy.

REFERENCES

1. Shaffer EA. Epidemiology of gallbladder stone disease. Best Pract Res Clin Gastroenterol. 2006;20(6):981–96.
2. Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part I: overall and upper gastrointestinal diseases. Gastroenterology. 2009;136(2):376–86.
3. Wani NA, Chowdri NA, Naqash SH, Parray FQ. Laparoscopic cholecystectomy: Conversion, complications. Trop Gastroenterol. 1999;20(4):180–2.
4. Navez B, Mutter D, Russier Y, Vix M, Jamali F, Lipski D, et al. Safety of laparoscopic approach for acute cholecystitis: Retrospective study of 609 cases. World J Surg. 2001;25(11):1352–6.
5. Kama NA, Kologlu M, Doganay M, Reis E, Atli M, Dolapci M. A risk score for conversion from laparoscopic to open cholecystectomy. Am J Surg. 2001;181(6):520–5.
6. Reynolds W The first laparoscopic cholecystectomy. JSLS. 2001;5(1):89–94.
7. Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev. 2006;4:CD006231.
8. Ryu JK, Lee JK, Lee KH, Woo SM, Lee WJ, Kim YT, et al. Predictive factors for difficult laparoscopic cholecystectomy in acute cholecystitis. Hepatogastroenterology. 2003;50(54):451–4.
9. Rosen M, Brody F, Ponsky J. Predictive factors for conversion of laparoscopic cholecystectomy. Am J Surg. 2002;184(3):254–8.
10. Dubois F, Icard P, Berthelot B, Levard H. Coelioscopic cholecystectomy: Preliminary report of 36 cases. Ann Surg. 1990;211(1):60–2.
11. Zucker KA. Difficult laparoscopic cholecystectomy. In: Surgical Laparoscopy. Philadelphia: Lippincott; 1991. p. 89–105.
12. Bingener J, Richards ML, Schwesinger WH, Strodel WE, Sirinek KR. Laparoscopic cholecystectomy for elderly patients: gold standard for golden years? Arch Surg. 2003;138(5):531–6.
13. Diehl AK. Epidemiology and natural history of gallstone disease. Gastroenterol Clin North Am. 1991;20(1):1–19.
14. Brodsky A, Matter I, Sabo E, Heyman Z, Cohen A, Abrahamson J, et al. Laparoscopic cholecystectomy for acute cholecystitis: can the need for conversion and the probability of complications be predicted? A prospective study. Surg Endosc. 2000;14(8):755–60.
15. Eldar S, Sabo E, Nash E, Abrahamson J, Matter I. Laparoscopic cholecystectomy for acute cholecystitis: prospective trial. World J Surg. 1997;21(5):540–5.
16. Kaushik B, Gupta S, Bansal S. C-reactive protein as a predictor of difficult laparoscopic cholecystectomy and conversion to open surgery. Int Surg J. 2018;5(7):2474–8.
17. Mok KW, Reddy R, Wood F, Turner P, Ward JB, Pursnani KG, et al. Is C-reactive protein a useful adjunct in selecting patients for emergency cholecystectomy by predicting severe or gangrenous cholecystitis? Int J Surg. 2014;12(7):649–53.
18. Randhawa JS, Pujahari AK. Preoperative prediction of difficult laparoscopic cholecystectomy: a scoring method. Indian J Surg. 2009;71(4):198–201.
19. Agrawal N, Singh S, Khichy S. Preoperative prediction of difficult laparoscopic cholecystectomy: a scoring method. Int Surg J. 2015;2(4):640–4.
20. Vivek MA, Augustine AJ, Rao R. A comprehensive predictive scoring method for difficult laparoscopic cholecystectomy. J Minim Access Surg. 2014;10(2):62–7.
21. Wevers KP, van Westreenen HL, Patijn GA. Prediction of conversion in patients undergoing early laparoscopic cholecystectomy for acute cholecystitis. Surg Endosc. 2013;27(5):1649–54.