Clinical evaluation of a surgical difficulty score for laparoscopic cholecystectomy for acute cholecystitis proposed in the Tokyo Guidelines 2018

Abstract Background/Purpose We evaluated the difficulty score of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) proposed in the Tokyo guidelines 2018 (TG18) and analyzed the most appropriate scoring method. Methods We reviewed 127 patients who underwent LC for AC from January 2018 to March 2022. According to TG18, surgical difficulty was scored for five categories consisting of 25 intraoperative findings. The median, highest, and mean score of the five categories were analyzed for their association with surgical outcomes. Results The difficulty score distribution (0/1/2/3/4/5/6) was as follows: median (8/34/43/30/12/0/0), highest (1/1/32/42/36/15/0) and mean (19/49/49/10/0/0/0). In all three scoring methods, higher difficulty scores were significantly correlated with longer operative time, more blood loss, and higher occurrence of subtotal cholecystectomy in trend tests. The areas under the curve (AUCs) for prediction of prolonged operative time minutes and increased blood loss were similar in all three scoring methods. For conversion to subtotal cholecystectomy, the AUC was significantly better for the highest than median and mean score ( p = .015 and p = .002, respectively). Conclusions The difficulty score in TG18 appropriately reflects the surgical difficulty of LC for AC. The median, highest, and mean scores of the five categories are all available, and the highest scores are simple and versatile.