Management of complicated gallstones: results of an alternative approach to difficult cholecystectomies.

Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstones. Nevertheless, the incidence of conversion and injuries to the biliary tract is still high in difficult cholecystectomies. In this study we sought to determine how using operative risk predictive scores (PSs) and the Nassar scale to grade the difficulty of LC would optimize the perioperative management of complicated gallstone patients. We also evaluated whether the "fundus-first" approach to LC combined with ultrasonic dissection minimizes the risk of conversion and biliary injury in difficult cholecystectomies, and avoids routine intraoperative cholangiography. A prospective non-randomized study was carried out from 2005 to 2007 including 237 patients referred for gallbladder diseases. All patients were evaluated using an operative risk PS. The LC grade of difficulty was assessed according to Nassar. Diagnostic accuracy, sensitivity, and specificity of PS were calculated. LC in difficult cases was accomplished with a fundus-first approach. Outcome measures included: Conversion rate, bile duct (BD) injury rate, and postoperative complications according to Clavien. In 178 out of 237 patients, a higher risk of conversion and complication was predicted. In 146 out of these 178 cases, intra-operative grading confirmed the difficulty of the procedure. The PS diagnostic accuracy was 0.865, sensitivity was 100%, and specificity 65%. Positive predictive value and negative predictive value were 0.82 and 1, respectively. Conversion rate was 2.7%. Mean operating time and postoperative length of hospital stay were 75 minutes and 3.5 days. Intra-operative cholangiography was necessary in five cases, and one intraoperative biliary complication occurred with an uneventful postoperative course. Overall, postoperative complications were 2.7% with a mortality rate of 0.68% (1 myocardial infarction). Fundus-first LC by ultrasonic dissection is safe and minimizes the risk of conversion and biliary injuries in difficult cases. Difficult cholecystectomies may be predicted preoperatively; in these cases the fundus-first approach and ultrasound dissection may be advised.