Preoperative C-Reactive Protein as a Predictor of Difficult Laparoscopic Cholecystectomy: A Prospective Observational Analysis

Background: Laparoscopic cholecystectomy (LC) is the gold standard for the treatment of symptomatic cholelithiasis. However, a subset of patients experience difficult laparoscopic cholecystectomy (DLC), which increases operative time, risk of complications, and likelihood of conversion to open surgery. Identifying clinical, sonological, and intraoperative predictors is essential for improving surgical outcomes. Aim: To evaluate the clinical, sonological, and intraoperative predictors of difficult laparoscopic cholecystectomy in patients with cholelithiasis. Methods: A prospective observational study was conducted on 148 patients undergoing LC at RNT Medical College and MB Hospital, Udaipur, from February 2024 to July 2025. Detailed clinical history, laboratory parameters including serum C-reactive protein (CRP), and ultrasonography findings were recorded. Intraoperative parameters such as gallbladder appearance, adhesions, bile/stone spillage, and duct/artery injury were assessed. Difficult LC was defined as operative time >60 minutes, significant bleeding, dense adhesions, difficult dissection of Calot’s triangle, or conversion to open surgery. Results: The mean age of patients was 45.5 years, with female predominance (75%). The most common symptom was abdominal pain (60%). Elevated CRP was significantly associated with operative difficulty, with mean CRP values rising from simple LC (22 mg/dl) to difficult LC (46 mg/dl) and converted cases (83 mg/dl). On ultrasonography, pericholecystic collection (31.7%), gallbladder wall thickening (24.3%), and impacted stones (10.1%) were common predictors. Intraoperatively, abnormal gallbladder appearance (43.9%) and pericholecystic adhesions (25%) were the main challenges. Difficult LC accounted for 21.6% of cases, while 4.7% required conversion to open surgery. Conclusion: Serum CRP levels, ultrasonographic findings (gallbladder wall thickening, pericholecystic collection, impacted stones), and intraoperative parameters (adhesions, abnormal gallbladder appearance) are reliable predictors of difficult laparoscopic cholecystectomy. Incorporating these predictors into preoperative assessment may enhance risk stratification, surgical planning, and patient safety.