# Laparoscopic cholecystectomy in a resource limited setting: Factors associated with difficult surgeries at the National Referral Hospital, Bhutan

## TL;DR

This study identifies factors linked to difficult laparoscopic cholecystectomy surgeries in Bhutan, showing that most cases were challenging but had low complication rates.

## Contribution

The study provides insights into factors associated with difficult surgeries in a resource-limited setting, contributing to surgical planning and patient care.

## Key findings

- 62% of laparoscopic cholecystectomy cases were classified as difficult.
- Simple adhesions to the gallbladder body increased the likelihood of difficult surgery.
- Post-operative complications were minimal, with no mortality or major injuries reported.

## Abstract

Prediction of difficult laparoscopic cholecystectomy may help in making necessary arrangements for optimal intraoperative requirements and postoperative care. This study was conducted to examine the factors associated with and outcomes of difficult laparoscopic cholecystectomy performed at the Bhutan's largest hospital in 2020.

This was a cross‐sectional study with a convenience sampling method. Data on clinical features, ultrasonography and intraoperative factors of patients who underwent laparoscopic cholecystectomy were extracted from their medical records, investigation reports and intraoperative surgery note. Difficult laparoscopic cholecystectomy was defined on the basis of the duration of the surgery, injury to bile duct or artery, or conversion to open cholecystectomy. Data were double entered and validated in EpiData 3.1 and analysed in STATA 13.0.

Data from 134 patients were extracted. The mean age of the sample was 43 (±SD 13) years. “Difficult laparoscopic cholecystectomy” was reported in 83 patients (62%) and easy laparoscopic cholecystectomy in 51 patients (38%). Those patients having simple adhesions up to the body of the gall bladder were 1.6 times more likely to encounter difficult laparoscopic cholecystectomy (adjusted PR = 1.60, 95% CI 1.04–2.48, p = 0.034). The majority did not have any post‐operative complications (130 cases, 97%). The indications of laparoscopic cholecystectomy were symptomatic gall stone disease (129, 96%), acalculous cholecystitis (2, 1%) and gall bladder polyp (3, 2%).

The proportion of difficult laparoscopic cholecystectomy is high, but the rates of post‐operative complications were minimal with no mortality or injury to bile duct or arteries.

Laparoscopic cholecystectomy is one of the most common surgical procedures performed globally. Dissection of Calot's triangle during a routine elective laparoscopic cholecystectomy in Bhutan, 2022.