PREOPERATIVE PREDICTORS OF DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY: A TWO-YEAR OBSERVATIONAL COHORT STUDY AT AL-HILLA TEACHING HOSPITAL, IRAQ

Zaid Ali Majeed

Авторы

Zaid Ali Majeed MBChB, ABGS., Assistant Professor, Consultant Surgeon, Department of Surgery, Al-Muthanna Medical College, Iraq

Ключевые слова:

Laparoscopic Cholecystectomy, Conversion to Open Surgery, Risk Factors, Preoperative Care, Obesity, Iraq

Аннотация

Laparoscopic cholecystectomy is the gold standard surgical treatment for symptomatic gallstone disease, but a significant minority of procedures are technically challenging and require either conversion to open operation or completion as subtotal cholecystectomy. Reliable preoperative identification of these cases would facilitate operative planning consent, and theatre scheduling. The goal of this study was to investigate the ability of four commonly accessible preoperative variables (i.e., male sex, advanced age, high body mass index [BMI], and history of upper abdominal surgery) as predictors for difficult laparoscopic cholecystectomy in an Iraqi teaching hospital. An observational cohort study was conducted in Al-Hilla Teaching Hospital from June 2010 to June 2012. Methods: The study was a prospective, randomized trial of 120 consecutive patients undergoing laparoscopic cholecystectomy for gallstone disease. Definition of difficult procedure Difficult procedures were defined a priori as requiring conversion to open cholecystectomy or completion as subtotal cholecystectomy. Data on sex, age, BMI and a history of prior upper abdominal surgery were collected pre-operatively. For categorical comparisons, the chi-square test with Yates continuity correction and the Fisher exact test were used–ORs are associated with 95% CI together with absolute risk differences (RD) and post-hoc power. The Holm method was performed for each of the four pairwise comparisons. The significance threshold for the two-sided p value was 35 kg/m² (20/40,50·0%, vs. 15/80,18·8%;OR:4·33;95%CI :1·88–10 ·00;p< 0·001). All three remained significant after Holm adjustment. In men, a complicated surgery was recorded in 20 of 55 (36.4%), and in women in 15 of 65 (23.1%); the difference favored male sex without reaching significance (OR 1·90, 95% CI 0·86–4·23; p = 0·163), with only a post-hoc power of just over if49%. Since the cohort was limited to patients between 30 and 65 years of age, this comparison actually compares patients aged 61–65 with a much younger group rather than comparing the very elderly with everyone else. Advanced age, history of upper abdominal surgery and degree of obesity (class II) were all independently significantly predictive of a difficult laparoscopic cholecystectomy while male sex exhibited a preferential non-significant trend in an underpowered sample size. All four variables are accessible at the bedside within minutes without any imaging or laboratory testing and will provide a defensible one-pass method of preoperative risk stratification in many resources deprived surgical practice. As this was a univariate analysis, the independence of these associations has yet to be determined.

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