Published: 2021-11-26

Pre-operative predictors of difficult laparoscopic cholecystectomy and its correlation with post-cholecystectomy syndrome and its impact on quality of life in North Indian population

Priyanka Agrawal, Mahboob Alam, Dhirendra Pratap, Krishna K. Singh, Lokesh Gupta, Utkarsh Tripathi


Background: Laparoscopic cholecystectomy (LC) is the most preferable surgical procedure worldwide. LC is not completely risk-free and 2 to 15% of attempted LC procedures have to be converted to open cholecystectomy. The aim of the study was to assess the predictors of difficult LC procedures and for knowing the impact of difficult LC procedures on post-cholecystectomy syndrome and quality of life of patients.

Methods: A prospective observational study was conducted on patients who underwent LC. Clinical, demographic, radiological and biochemical parameters along with detailed history of patients were documented. Laparoscopic cholecystectomy was then done on patients using standard technique. Level of difficulty in LC procedure was assessed and graded. Occurrence of post-cholecystectomy syndrome was investigated and quality of patient’s life was assessed using SF-36 inventory.

Results: The difficulty rate in LC procedure was observed to be 17.4%. The clinical predictors of difficult LC procedures were old age and prior history of abdominal surgery. Contracted gall bladder, peripancreatic fluid and thick gallbladder wall were radiological predictors and presence of adhesions, longer duration of surgery and conversion to open procedures were intraoperative predictors of difficult LC procedures. Early PCS was affected by difficult LC procedures; though with passage of time it reduced. Post-operative quality of life was affected more by PCS incidence than the difficult LC procedure.

Conclusions: The findings of the study would help in anticipating predictors of difficult LC procedures and in understanding the phenomenology and determinants of PCS along with its relationship with operative difficulty and quality of life of patients.


Laparoscopic cholecystectomy, Post-cholecystectomy syndrome, Quality of life, Radiological predictors, Clinical predictors, Biochemical predictors

Full Text:



Deziel DJ, Milikan KW, Economou SG. Complications of laparoscopic cholecystectomy: a national survey of 4292 hospitals and an analysis of 77604 cases. Am J Surg. 1993;165:9-14.

Silverstein A, Chavarri A, Gakwaya MR, Lule J, Mukhopadhyay S, Meara JG, et al. Laparoscopic versus open cholecystectomy: a cost-effectiveness analysis at Rwanda Military Hospital. World J Surg. 2017;41(5):1225-33.

Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy. The new 'gold standard'? Arch Surg. 2012;127(8):917-21.

Duca S, Bãlã O, Hajjar N. Laparoscopic cholecystectomy: incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations. HPB. 2003;5(3):152-8.

Bailey RW, Zucker KA, Flowers JL. Laparoscopic cholecystectomy. Arm Surg. 2017;214:531-41.

Lujan J, Parrilla P, Robles R, Marin P, Torralba J, Ayllon J. Laparoscopic Cholecystectomy vs Open Cholecystectomy in the Treatment of Acute Cholecystitis. Arch Surg. 1998;133(2):173-5.

Nidoni R, Udachan TV, Sasnur P, Baloorkar R, Sindgikar V, Narasangi B. Predicting Difficult Laparoscopic Cholecystectomy Based on Clinicoradiological Assessment. J Clin Diagn Res. 2015;9(12):9-12.

Gupta N, Ranjan G, Arora M, Goswami B, Chaudhary P, Kapur A, et al. Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg. 2013;11(9):1002-6.

Vivek MA, Augustine AJ, Rao R. A comprehensive predictive scoring method for difficult laparoscopic cholecystectomy. J Minim Access Surg. 2014;10(2):62-7.

Randhawa JS, Pujahari AK. Preoperative prediction of difficult lap chole: A scoring method. Indian J Surg. 2009;71:198-201.

Alponat A, Kum CK, Koh BC, Rajnakova A, Goh PM. Predictive factors for conversion of laparoscopic cholecystectomy. World J Surg. 1997;21:629-33.

Buono G, Romano G, Galia M. Difficult laparoscopic cholecystectomy and preoperative predictive factors. Sci Rep. 2021;11:2559.

Girometti R, Brondani G, Cereser L, Como G, Del PM, Bazzocchi M, et al. Post-cholecystectomy syndrome: spectrum of biliary findings at magnetic resonance cholangiopancreatography. Br J Radiol. 2010;83(988):351-61.

Latenstein CSS, Wennmacker SZ, Jong JJ, Laarhoven CJHM, Drenth JPH, Reuver PR. Etiologies of long-term postcholecystectomy symptoms: a systematic review. Gastroenterol Res Pract. 2019;2019:4278373.

Shirah BH, Shirah HA, Zafar SH, Albeladi KB. Clinical patterns of postcholecystectomy syndrome. Ann Hepatobiliary Pancreat Surg. 2018;22(1):52-7.

Jaunoo SS, Mohandas S, Almond LM. Postcholecystectomy syndrome (PCS). Int J Surg. 2010;8:15-17.

Serkan T, Kapakli MS, Senturk O, Selvi O, Serifsoy TE, Ozer Z. Evaluation of ultrasound-guided erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: A prospective, randomized, controlled clinical trial. J Clin Anesth. 2018;49:101-6.

Philip RJ, Burcharth J, Pommergaard HC, Viereck S, Rosenberg J. Preoperative risk factors for conversion of laparoscopic cholecystectomy to open surgery - a systematic review and meta-analysis of observational studies. Dig Surg. 2016;33(5):414-23.

Gupta AK. Predicting difficult laparoscopic cholecystectomy. Int Surg J. 2018;5(3):1094-9.

Ng HJ, Ahmed Z, Khan KS, Katbeh T, Nassar AHM. C-reactive protein level as a predictor of difficult emergency laparoscopic cholecystectomy. BJS Open. 2019;3(5):641-5.

Le VH, Smith DE, Johnson BL. Conversion of laparoscopic to open cholecystectomy in the current era of laparoscopic surgery. Am Surg. 2012;78(12):1392-5.

Ghamdi AS, Khamis HS, Shawatfy R, Khairy GA. Laparoscopic cholecystectomy: the outcome with minimal conversion rate: experience in a district hospital. Saudi J Gastroenterol. 2003;9(3):124-8.

Rashid T, Naheed A, Farooq U, Iqbal M, Barkat N. Conversion of laparoscopic cholecystectomy into open cholecystectomy: an experience in 300 cases. J Ayub Med Coll Abbottabad. 2016;28(1):116-9.

Yajima H, Kanai H, Son K, Yoshida K, Yanaga K. Reasons and risk factors for intraoperative conversion from laparoscopic to open cholecystectomy. Surg Today. 2014;44(1):80-3.

Ahmed O, Walsh TN. Surgical Trainee Experience with Open Cholecystectomy and the Dunning-Kruger Effect. J Surg Educ. 2020;77(5):1076-81.

Yueh TP, Chen FY, Lin TE, Chuang MT. Diarrhea after laparoscopic cholecystectomy: associated factors and predictors. Asian J Surg. 2014;37(4):171-7.

Dey A, Malik VK. Shoulder Tip Pain Following Laparoscopic Cholecystectomy-a Randomized Control Study to Determine the Cause. Indian J Surg. 2015;77(2):381-4.

Arora D, Kaushik R, Kaur R, Sachdev A. Post-cholecystectomy syndrome: A new look at an old problem. J Minim Access Surg. 2018;14(3):202-7.

Shirah BH, Shirah HA, Zafar SH, Albeladi KB. Clinical patterns of postcholecystectomy syndrome. Ann Hepatobiliary Pancreat Surg. 2018;22(1):52-57.

Shin Y, Choi D, Lee KG, Choi HS, Park Y. Association between dietary intake and postlaparoscopic cholecystectomic symptoms in patients with gallbladder disease. Korean J Intern Med. 2018;33(4):829-36.

Ito E, Takai A, Imai Y, Otani H, Onishi Y, Yamamoto Y, et al. Quality of life after single-incision laparoscopic cholecystectomy: A randomized, clinical trial. Surgery. 2019;165(2):353-9.

Chen L, Tao SF, Xu Y, Fang F, Peng SY. Patients' quality of life after laparoscopic or open cholecystectomy. J Zhejiang Univ Sci B. 2005;6(7):678-81.