Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy

Table 1 Predictors of difficult cholecystectomy[39,40,71]

History

Male gender

Higher age (> 65 yr)

Increased interval between onset and presentation (> 72-96 h) in acute cholecystitis

Previous multiple attacks of biliary colic

History of acute cholecystitis

Upper abdominal surgery

Prior attempt at cholecystectomy (including cholecystostomy)

Physical examination

Fever

Higher ASA score

Morbid obesity

Laboratory tests

Raised leucocyte count (> 18000/mm3)

Raised C-reactive protein

Imaging (USG/CT/MRI-MRCP)

Thick walled gallbladder (> 4-5 mm)

Small contracted gallbladder

Distended gallbladder with impacted stone in neck

Gangrenous gallbladder/gallbladder perforation

Mirizzi syndrome/Cholecystoenteric fistula

Cirrhosis/extrahepatic portal vein obstruction (portal cavernoma) with portal hypertension

Intraoperative

Small shrunken gallbladder not visualized on initial exploration

Liver edge retracted with fissure/depression/puckering near fundus (Liver pucker sign, Figure 3C)

Fatty/firm cirrhotic liver (difficulty in retraction)

ASA: American Society of Anesthesiologist; USG: Ultrasonography; CT: Computed Tomography; MRI-MRCP: Magnetic resonance imaging-magnetic resonance cholangiopancreatography.