Surgical Cholecystectomy Score (SCS) for grading the difficulty of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic gall stone disease. A good scoring system is necessary to standardize the reporting. Our aim was to develop and validate an objective scoring system, the Surgical Cholecystectomy Score (SCS) to grade the difficulty of LC. METHODS: The study was conducted in a single surgical unit at a tertiary care hospital in two phases from January 2017 to April 2021. Retrospective data was analysed and the difficulty of each procedure was graded according to the modified Nassar's scoring system. Significant preoperative and intraoperative data obtained was given a weightage score. In phase II, these scores were validated on a prospective cohort. Each procedure was classified either as easy, moderately difficult or difficult. STATISTICAL ANALYSIS: A univariate analysis was performed on the data followed by a multivariate regression analysis. Bidirectional stepwise selection was done to select the most significant variables. The Beta /Schneeweiss scoring system was used to generate a rounded risk score. RESULTS: Data of 800 patients was retrieved and graded. 10 intraoperative parameters were found to be significant. Each variable was assigned a rounded risk score. The final SCS range for intraoperative parameters was 0-15. The scoring system was validated on a cohort of 249 LC. In the final scoring, cut off SCS of > 8 was found to correlate with difficult procedures. Score of < 2 was equivalent to easy LC. A score between 2 and 8 indicated moderate difficulty. The area under ROC curve was 0.98 and 0.92 for the intraoperative score indicating that the score was an excellent measure of the difficulty level of LCs. CONCLUSION: The scoring system developed in this study has shown an excellent correlation with the difficulty of LC. It needs to be validated in different cohorts and across multiple centers further.

A comparative analysis of trans-abdominal pre-peritoneal repair in uncomplicated vs complicated inguinal hernia repair.

INTRODUCTION: Trans-abdominal pre-peritoneal (TAPP) repair is one of the standard techniques for laparoscopic repair of groin hernias. Literature has shown that both total extraperitoneal (TEP) and TAPP are equally effective with similar outcomes but TAPP has an advantage over TEP as there is more working space, and it provides access to the opposite side for repair of occult hernias. We reviewed our experience of TAPP repair in complicated groin hernias and compared the outcomes with uncomplicated groin hernia. METHODS: Patients undergoing TAPP repair from January 2004 to December 2019 were analyzed, and divided into two groups-I uncomplicated and II complicated groin hernia. RESULTS: TAPP repair was performed in 820 patients, of which 70.3% had uncomplicated and 29.7% patients had complicated hernias. Occult hernia was detected in 61 patients. The intra-operative complications (16.8% vs 1.3%) and conversions (2.4%) were higher in complicated hernias. Laparoscopic assisted repair was used in 16.8% patients with complicated hernias. The incidence of post-operative complications (62.1% vs 17.3%; P value <.01) were significantly higher in complicated groin hernia patients. The median follow-up was 15 months; only three patients in the uncomplicated hernia group developed recurrence, and chronic groin pain was higher in the complicated hernia repair patients (P > .05) at 6 months. CONCLUSION: Although operative time, incidence of intra-operative and post-operative complications (albeit minor in nature), and conversions to open are higher after TAPP repair for complicated groin hernias, the short-term outcomes (hematoma, mesh infection) as well as long-term outcomes (chronic groin pain, port site hernia and recurrence) are not different when compared with uncomplicated hernias. TAPP repair can be used in both complicated and uncomplicated groin hernias with similar short-term and long-term outcomes, albeit with a slightly higher incidence of minor complications in complicated hernias. This can be taken into consideration while operating on patients with complicated hernias and taking informed consent.