# Laparoscopic cholecystectomy after gallbladder preservation: TG18 Delphi score quantifies surgical difficulty

## TL;DR

This study shows that preserving the gallbladder increases surgical difficulty for later gallstone removal, using a scoring system to quantify the added complexity.

## Contribution

The study introduces the use of the TG18 Delphi score to objectively measure increased surgical difficulty after gallbladder preservation.

## Key findings

- Patients with prior gallbladder preservation had significantly higher TG18 scores due to fibrotic adhesions.
- Achieving the critical view of safety was less frequent in the gallbladder preservation group.
- TG18 scores above 25 predicted a fivefold increased risk of surgical conversion.

## Abstract

Despite cultural preferences for organ preservation in East Asia, choledochoscopic gallbladder-preserving surgery (CGPS) remains controversial given high recurrence rates. This study objectively quantified the increased technical complexity of laparoscopic cholecystectomy (LC) for recurrent cholecystolithiasis after prior CGPS using the Tokyo Guidelines 2018 (TG18).

In this propensity-matched study (1:1, n = 220) conducted between 2020 and 2025, patients requiring LC due to recurrent cholecystolithiasis after prior CGPS were compared with patients with primary cholecystolithiasis undergoing LC. Investigators matched groups for TG18 severity grading, BMI, and biliary anomalies. Two blinded surgeons assessed the intraoperative findings using TG18 Delphi scoring (7-point scale). Primary outcomes included difficulty scores, critical view of safety (CVS) achievement, and bile duct injury.

The CGPS group demonstrated significantly higher median TG18 scores (34 [IQR 30–39] vs. 21 [18–24]; adjusted mean difference: Δ 14.0 points, 95% CI: 11.2–16.8; p < 0.001), primarily due to fibrotic adhesions: Calot’s triangle dense fibrosis (49.1% vs. 6.4%), partial scarring (21.8% vs. 0.9%), and diffuse scarring (15.5% vs. 0%; all p < 0.001). Surgeons achieved CVS less frequently in the CGPS group (83.6% vs. 98.2%, p < 0.001). TG18 scores > 25 predicted a fivefold increased conversion risk (aOR = 4.9, 95% CI: 2.3–10.6).

Prior CGPS induces irreversible fibrosis that significantly increases reoperative difficulty (Δ 14 TG18 points), highlighting the need for careful patient selection in organ-preserving procedures. Definitive management with primary cholecystectomy remains the gold standard.