Grading operative findings at laparoscopic cholecystectomy- a new scoring system

Abstract

Introduction: Variation in outcomes from surgery is a major challenge and defining surgical findings may help set benchmarks, which currently do not exist in laparoscopic cholecystectomy. This study outlines a new surgical scoring system incorporating key operative findings.

Methods: English language studies (from January 1965 to July 2014) pertaining to severity scoring and predictors of difficult laparoscopic cholecystectomy were searched for in PubMed, Embase and Cochrane databases using the search terms 'Laparoscopic cholecystectomy or Lap chole' and/or 'Scoring Index or Grading system or Prediction of difficulty or Conversion to open' in various combinations. Cross-referencing from papers retrieved in the original search identified additional articles.

Results: Sixteen published papers report a gallbladder (GB) scoring system, but all relate to pre-operative clinical and imaging findings, rather than operative findings. The current scoring system, using operative findings incorporates the appearance of the GB, presence of GB distension, ease of access, potential biliary complications and time taken to identify cystic duct and artery. A score of <2 would imply mild difficulty, 2-4 moderate, 5-7 severe and 8-10 extreme.

Conclusion: This paper reports one of the first operative classifications of findings at laparoscopic cholecystectomy. It has the potential to allow benchmarks for international collaboration of operative and patient outcomes in patients undergoing laparoscopic cholecystectomy.

Keywords: Cholecystectomy; Cholecystitis; Conversion to open; Laparoscopic; Operative severity scoring system.

Figure 1

Schematic illustration of various intraoperative findings, with their respective scores: a. Normal gallbladder with no adhesions: 0 points. b. Adhesions covering < 50% of gallbladder: 1 point. c. Adhesions completely burying gallbladder: 3 points. d. Distended gallbladder, with inability to grasp with atraumatic laparoscopic forceps: 1 point. e. Large (>1 cm) stone impacted in Hartmann’s pouch: 1 point.

Figure 2

Intraoperative image demonstrating < 50% of gallbladder covered by adhesions (1 point).

Figure 3

Intraoperative image demonstrating gallbladder completely buried in adhesions (3 points).

Figure 4

Intraoperative image demonstrating a distended gallbladder (1 point), with < 50% of its surface area covered by adhesions (1 point).

Figure 5

Intraoperative image demonstrating severe sepsis/complications, with free bile (1 point, arrow) outside a distended (I point) gallbladder, covered by adhesions (3 points).