Introduction: Laparoscopic cholecystectomy has become the procedure of choice for the management of symptomatic gallstone disease. Difficulty in laparoscopic cholecystectomy is often encountered by surgeons and is associated with complications and a higher conversion rate. This study aims at identifying difficult laparoscopic cholecystectomies by clinical and imaging assessment and determining the utility of a pre-operative difficulty scoring system based on intra-operative findings. 

PATIENTS and METHODS: A hospital based observational study was conducted including all patients above age 18 years undergoing laparoscopic cholecystectomy. Randhawa’s preoperative score was calculated for every patient based on history, clinical and imaging parameters and the degree of operative difficulty was predicted. Another scoring was done using Sugrue’s scoring system based on intra-operative findings. The outcome factors studied were degree of operative difficulty or need for conversion and intra-operative and post-operative complications. The statistical analysis was done by using EPI INFO software version 7.

RESULTS: A total 84 patients with mean age 42.96 +14.34 years with 58 females and 26 males were enrolled. Of them 28 (33.33%) had difficult   laparoscopic cholecystectomies. The conversion rate to open cholecystectomy was 9.52%. Age above 50 years, prior history of acute cholecystitis, thickened gall bladder wall and stone impaction of Hartmann’s pouch were statistically significant pre-operative risk factors. The sensitivity of the preoperative score in identifying difficult cases was 85.7% with the specificity of 96.43%; positive predictive value of 92.31% and the negative predictive value of 93.10% and the accuracy was 92.86%. 

CONCLUSION: Pre-operative score and intra-operative findings are helpful in identifying difficult laparoscopic cholecystectomy.