A new framework for tailoring laparoscopic cholecystectomy: Integrating preoperative clinical factors with surgical difficulty based on the Tokyo Guidelines 2018

Abstract

Purpose: The Tokyo Guidelines 2018 introduced the Surgical Difficulty Score (TGDS18) to assess laparoscopic cholecystectomy (LC) difficulty based on intraoperative findings. This study aimed to predict surgical difficulty preoperatively using clinical factors correlated with TGDS18.

Methods: Of 369 LC cases for cholecystitis (Jan 2014-Jul 2024), 106 with operative video data were analyzed. Multivariate analysis of 69 with preoperative CT (≤14 days) evaluated the association between preoperative clinical findings and TGDS18 sub-scores (around the gallbladder, Calot's triangle, gallbladder bed, additional findings, unrelated to inflammation).

Results: TGDS18 was positively correlated with operative time, blood loss, and hospital stay (all p < .001). Patients undergoing subtotal cholecystectomy had higher TGDS18 scores (median 20, p < .001). Six preoperative findings strongly associated with TGDS18 sub-scores were identified: calcified stone in cystic duct, TG18 Grade ≥2, preoperative gallbladder drainage, urgent operation, pericholecystic inflammation, and age-adjusted Charlson comorbidity index ≥7. The rate of subtotal cholecystectomy increased with the number of findings linked to the "Calot's triangle" sub-score-cystic duct stone and TG18 Grade ≥2. (0% with no findings, 8% with one finding, and 23% with both, p = .009). Similarly, the risk of cholecystectomy requiring the posterior wall left can be predicted by the number of clinical findings related to the 'Gallbladder bed' sub-score (p = .009).

Conclusions: The clinical findings linked to TGDS18 allow tailored preoperative strategies for acute cholecystitis.

Keywords: Tokyo guideline 2018; acute cholecystitis; preoperative prediction; subtotal cholecystectomy; surgical difficulty score.

FIGURE 1

Correlation between surgical difficulty score and perioperative outcomes. The correlation between the surgical difficulty score (TGDS18) and perioperative outcomes (106 LC cases with video data were assessed). (a) Operative time (R = .593, p < .001) and (b) blood loss (R = .437, p < .001) showed a positive correlation with TGDS18. (c) Subtotal cholecystectomy cases had higher scores than cholecystectomy cases (p < .001). (d) Cases requiring open conversion had higher scores than cases without conversion (p = .059). (e) Postoperative length of hospital stay showed a positive correlation with TGDS18 (R = .570, p < .001). Scores were significantly higher in (f) cases with complications ≥Clavien‐Dindo Grade 3a (p = .048) and (g) cases with intra‐abdominal abscess (p = .071). LC, laparoscopic cholecystectomy; TGDS18, surgical difficulty score from Tokyo Guidelines 2018.

FIGURE 2

Association between six clinical preoperative findings and the difficulty sub‐scores. TGDS18 consists of the following sub‐scores: Appearance around the gallbladder, appearance of Calot's triangle, appearance of the gallbladder bed, additional findings related to the gallbladder and surroundings, and intra‐abdominal findings unrelated to inflammation. The analysis identified six preoperative clinical findings strongly associated with TGDS18 sub‐scores: A calcified stone in the cystic duct, TG18 Grade 2 or higher at onset, gallbladder drainage prior to LC, urgent operation, pericholecystic inflammation, and a higher age‐adjusted CCI (≥7). The relationships between these findings and TGDS18 sub‐scores were illustrated as key connections. CT findings of a calcified stone in the cystic duct and pericholecystic inflammation were obtained from plain CT scans performed within 14 days before surgery. CCI, Charlson comorbidity index; LC, laparoscopic cholecystectomy; TGDS18, surgical difficulty score from Tokyo Guidelines 2018; TG18, Tokyo Guidelines 2018.

FIGURE 3

Clinical factors increasing each difficulty sub‐score. We compared the difficulty scores between patients with and without at least one clinical factor associated with each TGDS18 sub‐score. Patients who had these factors exhibited significantly higher scores across all sub‐score categories, compared to those without factors: (a) For the sub‐score ‘around the gallbladder,’ median score of 2 vs. 0 (p < .001); (b) for ‘Calot's triangle,’ 4 vs. 0 (p < .001); (c) for ‘gallbladder bed,’ 4 vs. 0 (p < .001); (d) for ‘additional findings of the gallbladder and its surroundings,’ 4 vs. 0 (p < .001); and (e) for ‘intra‐abdominal findings unrelated to inflammation,’ 1 vs. 0 (p = .012). CT findings of a calcified stone in the cystic duct and pericholecystic inflammation were obtained from plain CT scans performed within 14 days before surgery. TGDS18, surgical difficulty score from Tokyo Guidelines 2018; TG18, Tokyo Guidelines 2018.

FIGURE 4

Prediction of subtotal cholecystectomy requirement based on clinical findings related to the ‘Calot's triangle’ sub‐score. (a) The difficulty sub‐score for ‘Calot's triangle’ was significantly higher in cases requiring subtotal cholecystectomy, compared to those undergoing total cholecystectomy (p = .003). (b) The rate of subtotal cholecystectomy increased proportionally with the number of two clinical factors associated with the elevated ‘Calot's triangle’ sub‐score: A calcified stone in the cystic duct and TG18 Grade 2 or higher at onset (0% in patients with no findings, 8% with one finding, and 23% with both findings, p = .009). TG18, Tokyo Guideliness 2018.

FIGURE 5

Prediction of cholecystectomy with the posterior wall left behind on the gallbladder bed based on clinical findings related to the “Gallbladder bed” sub‐score. (a) The difficulty sub‐score for the “Gallbladder bed” was significantly higher in cholecystectomy cases where the posterior wall was left behind, compared to those undergoing total cholecystectomy (p = .047). (b) The rate of cholecystectomy with the posterior wall left behind increased proportionally with the number of three clinical factors associated with the elevated “Gallbladder bed” sub‐score: A calcified stone in the cystic duct, TG18 Grade 2 or higher at onset, and gallbladder drainage prior to LC (0% for no factors, 6% for one factor, 18% for two factors, and 25% for three factors, p = .009). LC, laparoscopic cholecystectomy; TG18, Tokyo Guidelines 2018.