Implementing a modified intraoperative grading system for a difficult laparoscopic cholecystectomy

Objective: To analyze intraoperative grading findings during elective laparoscopic cholecystectomy by which we can assess the surgical performance regarding its safety, achievability and to determine a safe operative approach and/or time for conversion. Design: An observational prospective case series study. Setting: During the period from June 2018 to January 2020, operations were done by 4 qualified consultant surgeons and their teams at 4 hospitals in Mosul and Erbil. Participants: Two hundred and fifty-five patients. Patients and Methods: All patients underwent elective laparoscopic cholecystectomy for symptomatic gallbladder disease after full evaluation and taking their informed consents. An intraoperative difficulty calculation score has been implemented that divide the situation into 4 grades: easy, difficult, very difficult and extremely difficult, depending on the appearance of the gall bladder wall color, amount of adhesion, the presence of anatomical abnormalities, and the ability to achieve the critical view of safety. Perforation of the gallbladder, slipped stones, bleeding, using extra instruments, the need for extending the epigastric incision, the use of a drain and conversion to open procedure as well as the duration of surgical intervention had been recorded as predictors for the assessment of the difficulty level during surgery. Results: The first grade included 168 (66%) patients, the second grade included 62 (24%) patients, while grades 3 and 4 represent 15 (6%) and 10 (4%) of patients respectively. Perforation showed no significance in the grading. Bleeding was more common in grades 3 and 4. Using accessory equipment was mandatory to complete the operation in grade 4 as well as an extension of epigastric port and the need for putting a drain. Conversion to open cholecystectomy was done in 2 operations (0.7%), both belonged to grade 3 and 4. The time needed to accomplish the operation was significantly high in grades 3 and 4. Conclusion: This modified grading score can provide a tool for reporting operative findings and technical difficulties during laparoscopic cholecystectomy that allow the surgeon to know the seriousness of the situation and taking effective measures to overcome it.