A new framework for tailoring laparoscopic cholecystectomy: Integrating preoperative clinical factors with surgical difficulty based on the Tokyo Guidelines 2018

Abstract Purpose The Tokyo Guidelines 2018 introduced the Surgical Difficulty Score (TGDS18) to assess laparoscopic cholecystectomy (LC) difficulty based on intraoperative findings. This study aimed to predict surgical difficulty preoperatively using clinical factors correlated with TGDS18. Methods Of 369 LC cases for cholecystitis (Jan 2014–Jul 2024), 106 with operative video data were analyzed. Multivariate analysis of 69 with preoperative CT (≤14 days) evaluated the association between preoperative clinical findings and TGDS18 sub‐scores (around the gallbladder, Calot's triangle, gallbladder bed, additional findings, unrelated to inflammation). Results TGDS18 was positively correlated with operative time, blood loss, and hospital stay (all p < .001). Patients undergoing subtotal cholecystectomy had higher TGDS18 scores (median 20, p < .001). Six preoperative findings strongly associated with TGDS18 sub‐scores were identified: calcified stone in cystic duct, TG18 Grade ≥2, preoperative gallbladder drainage, urgent operation, pericholecystic inflammation, and age‐adjusted Charlson comorbidity index ≥7. The rate of subtotal cholecystectomy increased with the number of findings linked to the “Calot's triangle” sub‐score—cystic duct stone and TG18 Grade ≥2. (0% with no findings, 8% with one finding, and 23% with both, p = .009). Similarly, the risk of cholecystectomy requiring the posterior wall left can be predicted by the number of clinical findings related to the ‘Gallbladder bed’ sub‐score ( p = .009). Conclusions The clinical findings linked to TGDS18 allow tailored preoperative strategies for acute cholecystitis.