Biliary| Volume 171, ISSUE 5, P1158-1167, May 2022

Download started.


Statistical models to preoperatively predict operative difficulty in laparoscopic cholecystectomy: A systematic review

Published:November 11, 2021DOI:



      Laparoscopic cholecystectomy operative difficulty is highly variable and influences outcomes. This systematic review analyzes the performance and clinical value of statistical models to preoperatively predict laparoscopic cholecystectomy operative difficulty.


      PRISMA guidelines were followed. PubMed, Embase, and the Cochrane Library were searched until June 2020. Primary studies developing or validating preoperative models predicting laparoscopic cholecystectomy operative difficulty in cohorts of >100 patients were included. Studies not reporting performance metrics or enough information for clinical implementation were excluded. Data were extracted according to CHARMS, and study quality was assessed using the PROBAST tool.


      In total, 2,654 articles were identified, and 22 met eligibility criteria. Eighteen were model development, whereas 4 were validation studies. Eighteen studies were at high risk of bias. However, 11 studies showed low concern for applicability. Identified models predict 9 definitions of laparoscopic cholecystectomy operative difficulty, the most common being conversion to open surgery and operating time. The most validated models predict an intraoperative difficulty scale and procedures >90 minutes with an area under the curve of >0.70 and >0.76, respectively. Commonly used predictors include demographic variables such as age and gender (9/18 models) and ultrasound findings such as gallbladder wall thickness (11/18). Clinical implementation was never studied.


      There is a longstanding interest in estimating laparoscopic cholecystectomy operative difficulty. Models to preoperatively predict laparoscopic cholecystectomy operative difficulty have generally good performance and seem applicable. However, an unambiguous definition of operative difficulty, validations, and clinical studies are needed to implement patients’ stratification in laparoscopic cholecystectomy.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Pucher P.H.
        • Brunt L.M.
        • Davies N.
        • et al.
        Outcome trends and safety measures after 30 years of laparoscopic cholecystectomy: a systematic review and pooled data analysis.
        Surg Endosc. 2018; 32: 2175-2183
        • Iwashita Y.
        • Hibi T.
        • Ohyama T.
        • et al.
        Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework?.
        J Hepato-Biliary-Pancreat Sci. 2017; 24: 591-602
        • Fletcher R.
        • Cortina C.S.
        • Kornfield H.
        • et al.
        Bile duct injuries: a contemporary survey of surgeon attitudes and experiences.
        Surg Endosc. 2020; 34: 3079-3084
        • Törnqvist B.
        • Strömberg C.
        • Persson G.
        • Nilsson M.
        Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study.
        BMJ. 2012; 345: e6457
        • Berci G.
        • Hunter J.
        • Morgenstern L.
        • et al.
        Laparoscopic cholecystectomy: first, do no harm; second, take care of bile duct stones.
        Surg Endosc. 2013; 27: 1051-1054
        • Törnqvist B.
        • Waage A.
        • Zheng Z.
        • Ye W.
        • Nilsson M.
        Severity of acute cholecystitis and risk of iatrogenic bile duct injury during cholecystectomy, a population-based case-control study.
        World J Surg. 2016; 40: 1060-1067
        • Hussain A.
        Difficult laparoscopic cholecystectomy: current evidence and strategies of management.
        Surg Laparosc Endosc Percutan Tech. 2011; 21: 211-217
        • Michael Brunt L.
        • Deziel D.J.
        • Telem D.A.
        • et al.
        Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy.
        Surg Endosc. 2020; 34: 2827-2855
        • Hendriksen J.M.T.
        • Geersing G.J.
        • Moons K.G.M.
        • de Groot J.A.H.
        Diagnostic and prognostic prediction models.
        J Thromb Haemost. 2013; 11: 129-141
      1. Bouarfa L, Schneider A, Feussner H, et al. Prediction of intraoperative complexity from preoperative patient data for laparoscopic cholecystectomy. Artif Intell Med. 52:169–176.

        • Gholipour C.
        • Fakhree M.B.A.
        • Shalchi R.A.
        • Abbasi M.
        Prediction of conversion of laparoscopic cholecystectomy to open surgery with artificial neural networks.
        BMC Surg. 2009; 9: 13
        • Eldar S.
        • Siegelmann H.T.
        • Buzaglo D.
        • et al.
        Conversion of laparoscopic cholecystectomy to open cholecystectomy in acute cholecystitis: artificial neural networks improve the prediction of conversion.
        World J Surg. 2002; 26: 79-85
        • Stanisic V.
        • Andjelkovic I.
        • Vlaovic D.
        • et al.
        Feasibility of applying data mining techniques for predicting technical difficulties during laparoscopic cholecystectomy based on routine patient work-up in a small community hospital.
        Hepatogastroenterology. 2013; 60: 1561-1568
        • Hu A.S.Y.
        • Menon R.
        • Gunnarsson R.
        • de Costa A.
        Risk factors for conversion of laparoscopic cholecystectomy to open surgery: a systematic literature review of 30 studies.
        Am J Surg. 2017; 214: 920-930
        • Shamseer L.
        • Moher D.
        • Clarke M.
        • et al.
        Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation.
        BMJ. 2015; 350: g7647
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 339: b2700
        • Moons K.G.M.
        • de Groot J.A.H.
        • Bouwmeester W.
        • et al.
        Critical appraisal and data extraction for systematic reviews of prediction modelling studies: the CHARMS checklist.
        PLoS Med. 2014; 11e1001744
        • Moons K.G.M.
        • Wolff R.F.
        • Riley R.D.
        • et al.
        PROBAST: a tool to assess risk of bias and applicability of prediction model studies: explanation and elaboration.
        Ann Intern Med. 2019 01; 170: W1-W33
        • Steyerberg E.W.
        • Moons K.G.M.
        • van der Windt D.A.
        • et al.
        Prognosis Research Strategy (PROGRESS) 3: prognostic model research.
        PLoS Med. 2013; 10e1001381
        • Wolff R.F.
        • Moons K.G.M.
        • Riley R.D.
        • et al.
        PROBAST: a tool to assess the risk of bias and applicability of prediction model studies.
        Ann Intern Med. 2019; 170: 51-58
        • Vergouwe Y.
        • Steyerberg E.W.
        • Eijkemans M.J.C.
        • Habbema J.D.F.
        Substantial effective sample sizes were required for external validation studies of predictive logistic regression models.
        J Clin Epidemiol. 2005; 58: 475-483
        • Steyerberg E.W.
        Clinical Prediction Models.
        Springer, New York, NY2009 (Statistics for Biology and Health)
        • Sutcliffe R.P.
        • Hollyman M.
        • Hodson J.
        • et al.
        Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective U.K. database of 8820 patients.
        HPB. 2016; 18: 922-928
        • Tosun A.
        • Hancerliogullari K.O.
        • Serifoglu I.
        • Capan Y.
        • Ozkaya E.
        Role of preoperative sonography in predicting conversion from laparoscopic cholecystectomy to open surgery.
        Eur J Radiol. 2015; 84: 346-349
        • Bulbuller N.
        • Ilhan Y.S.
        • Baktir A.
        • Kirkil C.
        • Dogru O.
        Implementation of a scoring system for assessing difficult cholecystectomies in a single center.
        Surg Today. 2006; 36: 37-40
        • Lipman J.M.
        • Claridge J.A.
        • Haridas M.
        • et al.
        Preoperative findings predict conversion from laparoscopic to open cholecystectomy.
        Surgery. 2007; 142 (discussion 563–565): 556-563
        • Bourgouin S.
        • Mancini J.
        • Monchal T.
        • Calvary R.
        • Bordes J.
        • Balandraud P.
        How to predict difficult laparoscopic cholecystectomy? Proposal for a simple preoperative scoring system.
        Am J Surg. 2016; 212: 873-881
        • Kama N.A.
        • Kologlu M.
        • Doganay M.
        • Reis E.
        • Atli M.
        • Dolapci M.
        A risk score for conversion from laparoscopic to open cholecystectomy.
        Am J Surg. 2001; 181: 520-525
        • Sakuramoto S.
        • Sato S.
        • Okuri T.
        • Sato K.
        • Hiki Y.
        • Kakita A.
        Preoperative evaluation to predict technical difficulties of laparoscopic cholecystectomy on the basis of histological inflammation findings on resected gallbladder.
        Am J Surg. 2000; 179: 114-121
        • Bharamgoudar R.
        • Hodson J.
        • Griffiths E.
        • et al.
        The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy.
        Surg Endosc. 2018; 32
        • Nassar A.H.M.
        • Hodson J.
        • Ng H.J.
        • et al.
        Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system.
        Surg Endosc. 2020; 34: 4549-4561
        • Carbotta G.
        • Panebianco A.
        • Laforgia R.
        • et al.
        A new clinical-ultrasound score to predict difficult videolaparocholecystectomies: a prospective study.
        Ann Med Surg. 2018; 35: 59-63
        • Onoe S.
        • Maeda A.
        • Takayama Y.
        • Fukami Y.
        • Kaneoka Y.
        A preoperative predictive scoring system to predict the ability to achieve the critical view of safety during laparoscopic cholecystectomy for acute cholecystitis.
        HPB. 2017; 19: 406-410
        • Randhawa J.S.
        • Pujahari A.K.
        Preoperative prediction of difficult lap chole: a scoring method.
        Indian J Surg. 2009; 71: 198-201
        • AbdelDayem M.
        • Osgood L.
        • Escofet X.
        • Farag M.
        A new preoperative scoring system to predict difficulty of laparoscopic cholecystectomy and risk of conversion to open surgery.
        Indian J Surg. 2020; 82: 501-506
        • Siddiqui M.A.
        • Rizvi S.A.A.
        • Sartaj S.
        • Ahmad I.
        • Rizvi S.W.A.
        A standardized ultrasound scoring system for preoperative prediction of difficult laparoscopic cholecystectomy.
        J Med Ultrasound. 2017; 25: 227-231
        • Schrenk P.
        • Woisetschläger R.
        • Rieger R.
        • Wayand W.U.
        A diagnostic score to predict the difficulty of a laparoscopic cholecystectomy from preoperative variables.
        Surg Endosc. 1998; 12: 148-150
        • Goonawardena J.
        • Gunnarsson R.
        • de Costa A.
        Predicting conversion from laparoscopic to open cholecystectomy presented as a probability nomogram based on preoperative patient risk factors.
        Am J Surg. 2015; 210: 492-500
        • Kim M.S.
        • Kwon H.-J.
        • Park H.W.
        • et al.
        Preoperative prediction model for conversion of laparoscopic to open cholecystectomy in patient with acute cholecystitis: based on clinical, laboratory, and CT parameters.
        J Comput Assist Tomogr. 2014; 38: 727-732
        • Beksac K.
        • Turhan N.
        • Karaagaoglu E.
        • Abbasoglu O.
        Risk factors for conversion of laparoscopic cholecystectomy to open surgery: a new predictive statistical model.
        J Laparoendosc Adv Surg Tech A. 2016; 26: 693-696
        • Wennmacker S.Z.
        • Bhimani N.
        • Dijk AH van
        • Hugh T.J.
        • Reuver PR de
        Predicting operative difficulty of laparoscopic cholecystectomy in patients with acute biliary presentations.
        ANZ J Surg. 2019; 89: 1451-1456
        • Vohra R.S.
        • Spreadborough P.
        • Johnstone M.
        • et al.
        Protocol for a multicentre, prospective, population-based cohort study of variation in practice of cholecystectomy and surgical outcomes (the CholeS study).
        BMJ Open. 2015; 5e006399
        • Raza M.
        • M. V
        Predicting difficulty in laparoscopic cholecystectomy preoperatively using a scoring system.
        Int Surg J. 2019; 6: 957
        • Gupta N.
        • Ranjan G.
        • Arora M.P.
        • et al.
        Validation of a scoring system to predict difficult laparoscopic cholecystectomy.
        Int J Surg Lond Engl. 2013; 11: 1002-1006
        • Hu A.S.Y.
        • Donohue P.O.
        • Gunnarsson R.K.
        • de Costa A.
        External validation of the Cairns Prediction Model (CPM) to predict conversion from laparoscopic to open cholecystectomy.
        Am J Surg. 2018; 216: 949-954
        • Nassar A.H.M.
        Is laparoscopic cholecystectomy possible without video technology?.
        Minim Invasive Ther. 1995; 4: 63-65
        • Nassar A.H.M.
        • Ng H.J.
        • Wysocki A.P.
        • Khan K.S.
        • Gil I.C.
        Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure.
        Surg Endosc. 2020; 35: 6039-6047
        • Rothman J.P.
        • Burcharth J.
        • Pommergaard H.-C.
        • Rosenberg J.
        Cholecystectomy during the weekend increases patients’ length of hospital stay.
        World J Surg. 2016; 40: 849-855
        • Kaafarani H.M.A.
        • Smith T.S.
        • Neumayer L.
        • Berger D.H.
        • Depalma R.G.
        • Itani K.M.F.
        Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals.
        Am J Surg. 2010; 200: 32-40
        • Kama N.A.
        • Doganay M.
        • Dolapci M.
        • Reis E.
        • Atli M.
        • Kologlu M.
        Risk factors resulting in conversion of laparoscopic cholecystectomy to open surgery.
        Surg Endosc. 2001; 15: 965-968
        • Lee N.W.
        • Collins J.
        • Britt R.
        • Britt L.D.
        Evaluation of preoperative risk factors for converting laparoscopic to open cholecystectomy.
        Am Surg. 2012; 78: 831-833
        • Dexter S.P.
        • Martin I.G.
        • Marton J.
        • McMahon M.J.
        Long operation and the risk of complications from laparoscopic cholecystectomy.
        Br J Surg. 1997; 84: 464-466
        • Eijkemans M.J.C.
        • van Houdenhoven M.
        • Nguyen T.
        • Boersma E.
        • Steyerberg E.W.
        • Kazemier G.
        Predicting the unpredictable: a new prediction model for operating room times using individual characteristics and the surgeon’s estimate.
        Anesthesiology. 2010; 112: 41-49
        • Thiels C.A.
        • Yu D.
        • Abdelrahman A.M.
        • et al.
        The use of patient factors to improve the prediction of operative duration using laparoscopic cholecystectomy.
        Surg Endosc. 2017; 31: 333-340
        • Balciscueta I.
        • Barberà F.
        • Lorenzo J.
        • Martínez S.
        • Sebastián M.
        • Balciscueta Z.
        Ambulatory laparoscopic cholecystectomy: systematic review and meta-analysis of predictors of failure.
        Surgery. 2021; 170: 373-382
        • Iwashita Y.
        • Hibi T.
        • Ohyama T.
        • et al.
        An opportunity in difficulty: Japan-Korea-Taiwan expert Delphi consensus on surgical difficulty during laparoscopic cholecystectomy. J.
        Hepato-Biliary-Pancreat Sci. 2017; 24: 191-198
        • Nijssen M.A.J.
        • Schreinemakers J.M.J.
        • Meyer Z.
        • van der Schelling G.P.
        • Crolla R.M.P.H.
        • Rijken A.M.
        Complications after laparoscopic cholecystectomy: a video evaluation study of whether the critical view of safety was reached.
        World J Surg. 2015; 39: 1798-1803
        • van de Graaf F.W.
        • van den Bos J.
        • Stassen L.P.S.
        • Lange J.F.
        Lacunar implementation of the critical view of safety technique for laparoscopic cholecystectomy: results of a nationwide survey.
        Surgery. 2018; 164: 31-39
        • Felli E.
        • Mascagni P.
        • Wakabayashi T.
        • Mutter D.
        • Marescaux J.
        • Pessaux P.
        Feasibility and Value of the critical view of safety in difficult cholecystectomies.
        Ann Surg. 2019; 269: e41
        • Iwashita Y.
        • Ohyama T.
        • Honda G.
        • et al.
        What are the appropriate indicators of surgical difficulty during laparoscopic cholecystectomy? Results from a Japan-Korea-Taiwan multinational survey.
        J Hepato-Biliary-Pancreat Sci. 2016; 23: 533-547
        • Madni T.D.
        • Leshikar D.
        • Minshall C.T.
        • et al.
        The Parkland grading scale for cholecystitis.
        Am J Surg. 2018; 215: 625-630
        • Sarker S.K.
        • Chang A.
        • Vincent C.
        • Darzi S.A.W.
        Development of assessing generic and specific technical skills in laparoscopic surgery.
        Am J Surg. 2006; 191: 238-244
        • Nickel F.
        • Hendrie J.D.
        • Stock C.
        • et al.
        Direct observation versus endoscopic video recording-based rating with the objective structured assessment of technical skills for training of laparoscopic cholecystectomy.
        Eur Surg Res. 2016; 57: 1-9
        • Mascagni P.
        • Padoy N.
        OR black box and surgical control tower: recording and streaming data and analytics to improve surgical care.
        J Visc Surg. 2020; 158: S18-S25
        • Mascagni P.
        • Vardazaryan A.
        • Alapatt D.
        • et al.
        Artificial intelligence for surgical safety: automatic assessment of the critical view of safety in laparoscopic cholecystectomy using deep learning.
        Ann Surg. 2020 Nov 16; (Online ahead of print)
        • Mascagni P.
        • Alapatt D.
        • Urade T.
        • et al.
        A computer vision platform to automatically locate critical events in surgical videos: documenting safety in laparoscopic cholecystectomy.
        Ann Surg. 2021; 274: e93-e95
        • Strasberg S.M.
        • Brunt L.M.
        Rationale and use of the critical view of safety in laparoscopic cholecystectomy.
        J Am Coll Surg. 2010; 211: 132-138
        • Mascagni P.
        • Rodríguez-Luna M.R.
        • Urade T.
        • et al.
        Intraoperative time-out to promote the implementation of the critical view of safety in laparoscopic cholecystectomy: a video-based assessment of 343 procedures.
        J Am Coll Surg. 2021; S1072-7515 (00509-3)