Classification of Difficult Laparoscopic Cholecystectomy Based on Identification, Dissection and Procedural (IDP) Problems’ Solution

Aim: The aim of this research is to present the classification of difficult laparoscopic cholecystectomy based on additional procedures necessary for resolving intraoperative problems.

Material and Method: Laparoscopic cholecystectomy (LC) has four complexity levels under the classification based on the nature of additional procedures for solving identification, dissection and procedural (IDP) issues caused by pathological changes around the gallbladder and intraoperative complications: first level without identification, dissection and procedural (IDP) issues and managed by standard procedures, second level with the IDP problems solved by simple additional procedures, third level with problems solved by additional procedures which has complication risk, and fourth level requiring additional or alternative surgery. In this classification, the complexity levels can be determined by grading (on the basis of the “hardest” additional procedure applied in any stage of surgery) and points system (additional procedures carried out in each stage are assessed by points and the complexity level is determined by the sum of these points: points 0-2 - first level, points 3-8 – second level, points 9-15 – third level, points more than 16 – fourth level).

Results: This classification has been applied in 1695 patients who have undergone laparoscopic cholecystectomy for acute and chronic gallstone disease and gallbladder polyps: laparoscopic cholecystectomy of first level has been conducted in 44% of patients, second level – in 35.9%, third level – in 14.9% and fourth level – in 4.9%. In vast majority of patients (79.9%), laparoscopic cholecystectomy was completed with standard or simple procedures. In total, 3894 additional procedures were carried out, 3043 (78,1%) of which included simple procedures, 658 (16.8%) - risky procedures, and 193 (4.9%) - additional surgeries.

Conclusion: To determine the difficulty of laparoscopic cholecystectomy, four-level problem- resolving-based classification may be used which based on the nature of additional procedures to eliminate the identification, dissection and procedural (IDP) problems or complications during the surgery.