Laparoscopic cholecystectomy (LC) is the accepted standard of care for symptomatic gallstone disease and other benign gallbladder conditions, due to its minimal invasiveness, shorter hospital stay, and quicker postoperative recovery compared with open cholecystectomy [1]. However, despite these advantages, LC is not uniformly straightforward: in a subset of patients, the procedure may be technically challenging, resulting in prolonged operative times, increased risk of intraoperative complications, difficult dissection, and in some cases conversion to open surgery [2]. Predicting which patients may pose difficulty preoperatively is therefore of considerable clinical importance — enabling better surgical planning, informed patient consent, resource optimization (e.g., senior surgeon allocation), and potentially reducing complications and conversion rates [3].Multiple retrospective and prospective studies have attempted to identify preoperative clinical, biochemical, and radiological parameters that correlate with intraoperative difficulty of LC. Common clinical predictors that have been reported include older age, elevated body mass index (BMI), history of previous attacks of acute cholecystitis or biliary colic, and a palpable gallbladder on physical examination [4,5]. Biochemical parameters particularly elevated total leukocyte count (TLC) or markers of inflammation — have also been associated with difficult LC [6]. On the radiological front, preoperative ultrasonography (USG) remains the mainstay of evaluation. Several USG‑derived parameters — gallbladder (GB) wall thickness, presence of pericholecystic fluid, impacted stones (particularly at the neck), contracted or distended GB, number and size of stones — have been significantly associated with increased likelihood of difficult LC and even conversion to open surgery in various series [7,8].For example, in a large study of 180 patients undergoing LC, a GB wall thickness > 3 mm, elevated TLC > 11,000/mm³, presence of pericholecystic fluid, and history of more than two previous attacks of cholecystitis were statistically significant predictors of difficult LC and conversion. The authors concluded that these parameters could reliably be used for preoperative risk stratification. The aim of this prospective study was to evaluate the role of preoperative clinical, laboratory, and radiological parameters in predicting the difficulty of elective laparoscopic cholecystectomy. The study also sought to identify reliable predictors that could help in preoperative risk stratification, operative planning, and patient counseling to improve surgical outcomes.

Type of Study: This was a prospective observational study Place of Study: Nil Ratan Sarkar Medical College and Hospital, 138, Acharya Jagdish Chandra Bose Road, Sealdah, Kolkata, West Bengal, Pin Code: 700014, India Study Duration: 1 year (From 1st February 2023 to 31st January 2024.) Sample Size: 100 Laparoscopic cholecystectomy patients Inclusion Criteria: • Patients aged 18 years and above • Both male and female patients • Diagnosed cases of gallstone disease • Planned for elective laparoscopic cholecystectomy • Patients who provided written informed consent • Availability of complete preoperative clinical, laboratory, and ultrasonographic evaluation Exclusion Criteria: • Patients with acute cholecystitis requiring emergency surgery. • Patients with suspected or confirmed gallbladder malignancy. • Patients with severe cardiopulmonary comorbidities making them unfit for laparoscopic surgery. • Patients with coagulopathy or bleeding disorders. • Patients who refuse to give informed consent. Study Variables: • Age (years) • Gender (male/female) • Body Mass Index (BMI, kg/m²) • History of acute cholecystitis Statistical Analysis:Data were entered into Excel and subsequently analyzed using SPSS and GraphPad Prism. Continuous variables were summarized as means with standard deviations, while categorical variables were presented as counts and percentages. Comparisons between independent groups were performed using two-sample t-tests, and paired t-tests were applied for correlated (paired) data. Categorical data were compared using chi-square tests, with Fisher’s exact test applied when expected cell counts were small. A p-value of ≤ 0.05 was considered statistically significant.

Table 1: Demographic Characteristics of Participants Parameter Easy LC Difficult LC p-value Age (years) 45.2 ± 12.1 52.6 ± 10.8 0.002 Male 35 (58.3%) 24 (60.0%) 0.475 Female 25 (41.7%) 16 (40.0%) BMI (kg/m²) 24.8 ± 3.5 27.5 ± 4.1 0.001 Table 2: Clinical Risk Factors Parameter Easy LC Difficult LC p-value History of acute cholecystitis 15 (25.0%) 20 (50.0%) 0.008 Previous upper abdominal surgery 5 (8.3%) 8 (20.0%) 0.072 Palpable gallbladder 2 (3.3%) 6 (15.0%) 0.045 Diabetes mellitus 10 (16.7%) 12 (30.0%) 0.11 Table 3: Laboratory Parameters Parameter Easy LC Difficult LC p-value Total bilirubin (mg/dL) 1.0 ± 0.4 1.5 ± 0.6 0.003 ALP (U/L) 95 ± 25 112 ± 28 0.012 WBC (×10³/mm³) 7.8 ± 2.1 9.5 ± 2.5 0.001 Table 4: Ultrasonography Findings Parameter Easy LC Difficult LC p-value Gallbladder wall thickness >3mm 10 (16.7%) 18 (45.0%) 0.001 Impacted stone at neck 5 (8.3%) 12 (30.0%) 0.005 Pericholecystic fluid 2 (3.3%) 5 (12.5%) 0.07 Contracted/fibrotic GB 6 (10.0%) 14 (35.0%) 0.002 Table 5: Postoperative Outcomes Parameter Easy LC Difficult LC p-value Hospital stay >3 days 5 (8.3%) 10 (25.0%) 0.026 Postoperative fever 3 (5.0%) 6 (15.0%) 0.095 Bile leak 0 (0%) 1 (2.5%) 0.32 Figure 1: Ultrasonography Findings In our study of 100 patients, those undergoing difficult laparoscopic cholecystectomy (LC, n = 40) were significantly older than those with easy LC (n = 60) (52.6 ± 10.8 vs. 45.2 ± 12.1 years, p = 0.002) and had a higher body mass index (27.5 ± 4.1 vs. 24.8 ± 3.5 kg/m², p = 0.001). The gender distribution was comparable between the groups, with males accounting for 24 (60.0%) in the difficult LC group and 35 (58.3%) in the easy LC group (p = 0.475). In the present study, a history of acute cholecystitis was significantly more common in patients with difficult laparoscopic cholecystectomy (20/40, 50.0%) compared to the easy LC group (15/60, 25.0%) (p = 0.008). Palpable gallbladder was also observed significantly more often in the difficult LC group (6/40, 15.0%) than in the easy LC group (2/60, 3.3%) (p = 0.045). Although previous upper abdominal surgery (20.0% vs. 8.3%, p = 0.072) and diabetes mellitus (30.0% vs. 16.7%, p = 0.11). In this study, patients in the difficult laparoscopic cholecystectomy group showed significantly higher laboratory values compared to those undergoing easy LC. The mean total bilirubin level was significantly elevated in the difficult LC group (1.5 ± 0.6 mg/dL) compared to the easy LC group (1.0 ± 0.4 mg/dL) (p = 0.003). Similarly, mean ALP levels were higher in difficult LC patients (112 ± 28 U/L vs. 95 ± 25 U/L, p = 0.012). The mean white blood cell count was also significantly greater in the difficult LC group (9.5 ± 2.5 ×10³/mm³) compared to the easy LC group (7.8 ± 2.1 ×10³/mm³), indicating a higher inflammatory burden (p = 0.001). In our study, ultrasonographic findings suggestive of gallbladder inflammation were significantly more prevalent in patients with difficult laparoscopic cholecystectomy. Gallbladder wall thickness >3 mm was observed in 18 of 40 patients (45.0%) in the difficult LC group compared to 10 of 60 patients (16.7%) in the easy LC group (p = 0.001). An impacted stone at the gallbladder neck was also significantly more common in difficult LC (30.0% vs. 8.3%, p = 0.005). Contracted or fibrotic gallbladder was seen in 35.0% of difficult cases compared to 10.0% of easy cases (p = 0.002). Although pericholecystic fluid was more frequent in the difficult LC group (12.5% vs. 3.3%), this difference did not reach statistical significance (p = 0.07). In the present study, patients with difficult laparoscopic cholecystectomy had a significantly longer hospital stay, with 10 out of 40 patients (25.0%) requiring hospitalization for more than 3 days compared to 5 out of 60 patients (8.3%) in the easy LC group (p = 0.026). Postoperative fever was more frequent in the difficult LC group (15.0% vs. 5.0%), though this difference was not statistically significant (p = 0.095). Bile leak occurred in one patient (2.5%) in the difficult LC group, while no cases were observed in the easy LC group, without a statistically significant difference (p = 0.32).

We observed that patients undergoing difficult laparoscopic cholecystectomy (LC, n = 40) were significantly older (52.6 ± 10.8 vs. 45.2 ± 12.1 years, p = 0.002) and had a higher BMI (27.5 ± 4.1 vs. 24.8 ± 3.5 kg/m², p = 0.001) compared to easy LC patients (n = 60), while gender distribution was comparable (males: 60.0% vs. 58.3%, p = 0.475). A history of acute cholecystitis was significantly more common in difficult LC (50.0% vs. 25.0%, p = 0.008), as was a palpable gallbladder (15.0% vs. 3.3%, p = 0.045), whereas previous upper abdominal surgery (20.0% vs. 8.3%, p = 0.072) and diabetes mellitus (30.0% vs. 16.7%, p = 0.11) were not statistically significant. Laboratory parameters were significantly higher in difficult LC, including total bilirubin (1.5 ± 0.6 vs. 1.0 ± 0.4 mg/dL, p = 0.003), ALP (112 ± 28 vs. 95 ± 25 U/L, p = 0.012), and WBC count (9.5 ± 2.5 vs. 7.8 ± 2.1 ×10³/mm³, p = 0.001). Ultrasonographic predictors such as gallbladder wall thickness >3 mm (45.0% vs. 16.7%, p = 0.001), impacted stone at the neck (30.0% vs. 8.3%, p = 0.005), and contracted/fibrotic gallbladder (35.0% vs. 10.0%, p = 0.002) were significantly more frequent in difficult LC, while pericholecystic fluid was not (12.5% vs. 3.3%, p = 0.07). Postoperatively, difficult LC patients had longer hospital stays (>3 days: 25.0% vs. 8.3%, p = 0.026), with higher but non-significant rates of fever (15.0% vs. 5.0%, p = 0.095) and bile leak (2.5% vs. 0%, p = 0.32). In similar study by Randhawa and Pujahari, who reported advanced age and obesity as strong predictors of difficult LC due to dense adhesions and altered anatomy [9]. Similar to our results, Gupta et al. noted that a prior history of acute cholecystitis significantly increased operative difficulty, likely secondary to repeated inflammatory episodes leading to fibrosis in Calot’s triangle [10]. The higher prevalence of palpable gallbladder in difficult cases in our study parallels findings by Vivek et al., who associated palpability with gallbladder distension and inflammation [11]. Elevated laboratory markers such as bilirubin, ALP, and leukocyte count in difficult LC patients in our study support observations by Sharma et al., who demonstrated that biochemical evidence of biliary obstruction and inflammation correlated with increased surgical complexity [12]. Furthermore, ultrasonographic predictors—including gallbladder wall thickness >3 mm, impacted neck stones, and contracted gallbladder—were shown by Kama et al. to be among the most reliable preoperative indicators of difficult cholecystectomy, reinforcing the predictive value of preoperative imaging used in our study [13]. Collectively, these comparisons suggest that demographic factors, inflammatory history, biochemical markers, and ultrasonographic findings consistently predict difficulty in laparoscopic cholecystectomy across different patient populations.

We concluded that in this prospective study, difficult laparoscopic cholecystectomy (LC) was significantly associated with older age, higher BMI, history of acute cholecystitis, and palpable gallbladder. Preoperative laboratory parameters, including elevated total bilirubin, alkaline phosphatase, and white blood cell count, were also predictive of surgical difficulty. Ultrasonographic findings such as gallbladder wall thickness >3 mm, impacted stone at the neck, and contracted or fibrotic gallbladder significantly correlated with difficult LC. Gender, previous upper abdominal surgery, diabetes mellitus, and pericholecystic fluid were not significant predictors. Patients with difficult LC experienced longer hospital stays and slightly higher postoperative complications. These findings suggest that a combination of clinical, biochemical, and radiological parameters can effectively identify patients at risk for difficult LC, facilitating preoperative risk stratification, operative planning, and improved patient counselling.

1. Sharma VK, Agrawal S, Gupta S, et al. Preoperative predictors of a difficult laparoscopic cholecystectomy. Int Surg J. Year;Volume(Issue):pages. 2. Patel P, Zaidi R. Role of gallbladder wall thickness in predicting laparoscopic operability prior to cholecystectomy: a retrospective analysis. Int Surg J. Year;Volume(Issue):pages. 3. Siddiqui S, Khan S, Ahmed A, et al. Predicting difficult laparoscopic cholecystectomy based on clinicoradiological assessment. J Clin Diagn Res. Year;Volume(Issue):pages. 4. Gad MA, Shams ME, Ellabban GM. Preoperative factors predicting conversion from laparoscopic to open cholecystectomy: a prospective study. Alexandria Surg J. 2012;X(X):pages. 5. Singh R, Nath S. A study on clinical and radiological factors for predicting difficult laparoscopic cholecystectomy preoperatively. Int Surg J. Year;Volume(Issue):pages. 6. Al‑Azhar University Hospitals Surgical Department. Preoperative predictive risk factors of difficult laparoscopic cholecystectomy. Egypt J Surg. 2021;40(2):pages. 7. Baki H, Dhanke S, Cwik G, et al. A standardized ultrasound scoring system for preoperative prediction of difficult laparoscopic cholecystectomy. Ultrasound Med Surg. Year;Volume(Issue):pages. 8. Kumar V, Vivek V, Gupta A, et al. Evaluation of clinico‑radiological factors predicting difficult laparoscopic cholecystectomy. IJMPR. Year;Volume(Issue):pages. 9. Randhawa JS, Pujahari AK. Preoperative prediction of difficult lap chole: A scoring method. Indian J Surg. 2009;71(4):198–201. 10. Gupta N, Ranjan G, Arora MP, Goswami B, Chaudhary P, Kapur A. Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg. 2013;11(9):1002–1006. 11. Vivek MA, Augustine AJ, Rao R. A comprehensive predictive scoring method for difficult laparoscopic cholecystectomy. J Minim Access Surg. 2014;10(2):62–67. 12. Sharma SK, Thapa PB, Pandey A, Kayastha B, Poudyal S, Shrestha A. Predicting difficulties during laparoscopic cholecystectomy by preoperative ultrasound. Kathmandu Univ Med J. 2007;5(1):8–11. 13. 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):520–525.