Defining preoperative predictors of difficult laparoscopic cholecystectomy in children

Abstract Purpose Studies in adult populations have reported preoperative predictors of difficult laparoscopic cholecystectomy, but paediatric data are not available. Predicting challenging cases permits improved operative planning. Methods Retrospective analysis of all laparoscopic cholecystectomies [LC] by three sub-specialist surgeons June 2017–April 2024. Difficult LC was defined by the presence of either: [i] operative time > 150 min; [ii] open conversion; [iii] additional surgeon consulted; [iv] anatomical variant; [v] significant bleeding/synthetic haemostatics. Logistic regression compared clinical, laboratory, and imaging findings between difficult LC and uncomplicated LC groups. Data are presented as median [IQR] with odds ratio [OR] [95th C.I]. Results 133 children [age 13 (1–15)], 81/133 [60.9% female]. Indications for surgery included biliary colic [64.7%], pancreatitis [17.3%], and others [18%]. 35/133 [26.3%] were defined as difficult LC. Significant predictors of difficult LC included: emergency admission [OR 6.18 (2.55–14.9), p = 0.000], history of pancreatitis [OR 2.96 (1.3–6.9), p = 0.01], history of cholecystitis [OR 3.57 (1.52–8.4), p = 0.003], LC during acute cholecystitis [OR 12.7 (3.2–49.5), p = 0.000], LC during acute pancreatitis [OR 3.33 (1.1–9.7), p = 0.03], raised WCC [OR 1.1 (1.03–1.18), p = 0.004], raised CRP [1.005 (1.001–1.01), p = 0.03], raised ALT [OR 1.007 (1.002–1.01), p = 0.01], hypoalbuminaemia [OR 0.86 (0.80–0.94), p = 0.00] and raised lipase OR 1.009 (1.001–1.02), p = 0.02], C-reactive to Albumin Ratio [OR 1.22 (1.04–1.44), p = 0.02, ultrasound diagnosis of acute cholecystitis [OR 7.44 (2.33–23.8), p = 0.001], thickened gallbladder [OR 3.52 (1.31–9.4), p = 0.001], impacted stone [OR 3.7 (1.5–9.4), p = 0.005], and bile duct dilation [OR 4.32 (1.84–10.1), p = 0.001]. Conclusion Multiple predictors of difficult LC were identified. These predictors can be used to alert teams to consider whether extra resources may be required e.g., on-table cholangiogram, more operative time, or availability of additional surgeons.