Preoperative difficulty factors in delayed laparoscopic cholecystectomy: Tokyo Guidelines 2018 surgical difficulty score analysis

Abstract Introduction Tokyo Guidelines 2018 (TG18) recommend early laparoscopic cholecystectomy (LC) for low‐risk acute cholecystitis (AC); however, some patients undergo delayed LC (DLC) after conservative treatment. DLC, influenced by chronic inflammation, is a difficult procedure. Previous studies on LC difficulty lacked objective measures. Recently, TG18 introduced a novel 25 findings difficulty score, which objectively assesses intraoperative factors. The purpose of this study was to use the difficulty score proposed in TG18 to identify and investigate the predictors of preoperative high‐difficulty cases of DLC for AC. Methods We retrospectively reviewed 100 patients with DLC after conservative AC treatment. The surgical difficulty of DLC was evaluated using a difficulty score. Based on previous studies, the highest scores in each category were categorized as grades A–C. Results The severity of AC was mild in 51 patients and moderate in 49. Surgical outcomes revealed a distribution of difficulty scores, with grade C indicating high difficulty, showing significant differences in operative time, blood loss, achieving a critical view of safety, bailout procedures, and postoperative hospital stay compared with grades A and B. Regarding the preoperative risk factors, multivariate analysis identified age >61 years ( p = .008), body mass index >27.0 kg/m 2 ( p = .007), and gallbladder wall thickness >6.2 mm ( p = .001) as independent risk factors for grade C in DLC. Conclusion The difficulty score proposed in TG18 provides an objective framework for evaluating surgical difficulty, allowing for more accurate risk assessments and improved preoperative planning in DLC for AC.