Clinico-Radiological Score for Predicting the Difficulty of Laparoscopic Cholecystectomy in Acute Calculous Cholecystitis

Background: Acute calculous cholecystitis is a common surgical condition for which early laparoscopic cholecystectomy is the standard treatment. However, operative difficulty varies widely and is often unpredictable, leading to increased complications and technical challenges. Accurate preoperative prediction of operative difficulty is essential for surgical planning, patient counseling, and optimizing outcomes. This study aimed to develop a clinico-radiological scoring system using preoperative parameters to predict operative difficulty in patients with acute calculous cholecystitis. Material and Methods: This retrospective observational study included adult patients with acute calculous cholecystitis who underwent laparoscopic cholecystectomy at a tertiary care center between February 2022 and August 2023. Clinical, laboratory, and ultrasonographic parameters were collected from medical records. Operative difficulty was categorized as easy or difficult based on intraoperative findings documented in operative notes. Univariate analysis was performed using independent t-tests and chi-square tests, followed by multivariate linear regression analysis to identify independent predictors. A preoperative clinico-radiological scoring system was constructed based on regression coefficients and statistical significance. Correlation between the preoperative score and operative difficulty was assessed using Spearman's rank correlation coefficient. Results: A total of 183 patients were included, of whom 77 (42.1%) underwent difficult laparoscopic cholecystectomy. Elevated C-reactive protein levels and neutrophil-to-lymphocyte ratio were significantly associated with operative difficulty on univariate analysis. Clinical factors such as positive Murphy's sign and prior endoscopic retrograde cholangiopancreatography showed strong associations. Radiological predictors included increased gallbladder wall thickness, multiple gallstones, stone impaction at the gallbladder neck, and presence of pericholecystic fluid. Multivariate linear regression analysis identified Murphy's sign, prior endoscopic retrograde cholangiopancreatography, elevated C-reactive protein levels, gallbladder wall thickness, and stone impaction at the gallbladder neck as independent predictors (R² = 0.863). The derived scoring system ranged from 0 to 13 and demonstrated strong correlation with operative difficulty (Spearman's ρ = 0.796, p < 0.001). A score ≥ 7 was significantly associated with difficult laparoscopic cholecystectomy (p < 0.001). Conclusion: The proposed clinico-radiological scoring system, based on routine preoperative clinical, laboratory, and ultrasonographic parameters, is a reliable tool for predicting operative difficulty in laparoscopic cholecystectomy for acute calculous cholecystitis. This scoring system may assist surgeons in preoperative risk stratification, surgical planning, and patient counseling, thereby improving operative preparedness and outcomes.

Keywords: Acute calculous cholecystitis, c-reactive protein, difficult laparoscopic cholecystectomy, gallbladder wall thickness, laparoscopic cholecystectomy, preoperative scoring system, stone impaction, ultrasonography.