REDEFINING SURGICAL COMPLEXITY IN ACUTE CHOLECYSTITIS: A MULTI-PARAMETRIC ANALYSIS OF PREOPERATIVE PREDICTORS AND OPERATIVE TIME THRESHOLDS

Background: Acute cholecystitis (AC) is a common surgical emergency, with laparoscopic cholecystectomy (LC) being the gold standard. However, the technical difficulty of LC varies significantly, influenced by local inflammation and anatomical distortions. Accurate preoperative prediction of surgical complexity is vital for optimizing operative planning, enhancing patient safety, and improving outcomes. This study aims to identify independent preoperative clinical, biochemical, and radiological predictors of surgical difficulty, defined by an operative time threshold of 50 minutes, in patients undergoing emergency LC for AC in a Syrian tertiary care setting. Methods: This single-center, retrospective observational study analyzed data from 49 consecutive adult patients who underwent emergency LC for AC at AlAbbassieen Hospital between January 0202 and December 0202. Demographic data, preoperative inflammatory markers (White Blood Cell count [WBC] and C-reactive protein [CRP]), and ultrasonographic findings (gallbladder wall thickness and pericholecystic fluid) were collected. Operative difficulty was defined as an operative time of 50 minutes or more. Statistical analysis included independent samples t-tests (Welch's), Chi-square tests, and multivariate logistic regression. A power analysis was also conducted for key predictors. Results: Forty-nine patients were included (mean age 58.9 ± 11.9 years; 57.1% male). The median operative time was 50 minutes, with 28 patients (57.1%) classified as having difficult LC (operative time ≥ 50 minutes). Univariate analysis revealed significantly higher mean CRP levels in the difficult LC group (51.66 mg/L) compared to the easy LC group (25.38 mg/L) (p = 0.026). WBC count (p=0.086), pericholecystic fluid (p=0.160), severe adhesions (p=0.080), and empyema/gangrene (p=0.070) showed trends towards association with operative difficulty. Multivariate logistic regression, while limited by sample size, indicated odds ratios for pericholecystic fluid (OR=3.91, 95% CI: 0.56-38.81) and severe adhesions (OR=4.81, 95% CI: 0.56-59.20) suggesting potential independent predictive value. A power analysis for CRP indicated a power of 0.59 for detecting the observed difference with the current sample size. Conclusion: Preoperative CRP levels, WBC count, and ultrasonographic findings, particularly the presence of pericholecystic fluid and severe adhesions, demonstrate strong trends in predicting surgical difficulty in emergency LC for AC. Utilizing a 50-minute operative time threshold effectively stratifies cases by complexity, aiding in preoperative risk assessment and potentially guiding surgical strategy in settings with skilled surgeons. These findings underscore the importance of comprehensive preoperative evaluation to anticipate and manage challenging cases, ultimately enhancing patient outcomes.