Utilization of an Intraoperative Grading Scale in Laparoscopic Cholecystectomy: A Nepalese Perspective

Abstract

Introduction. Difficult geographic diversity and late presentation to medical attention often make the laparoscopic cholecystectomy difficult and chances of conversion and complication remains. Various preoperative grading scales have been developed for predicting the difficulty of surgery in cholecystitis patients; however, intraoperative assessment of anatomical status and inflammation of the gall bladder has not been assessed till date except for some guidelines like the Parkland grading scale (PGS). We aimed to utilise this guideline in patients undergoing laparoscopic cholecystectomy in rural community of the developing nation. Methods. PGS was applied for all the patients undergoing laparoscopic cholecystectomy and laboratory and outcome factors like preoperative white blood cells (WBC), open conversion, subtotal cholecystectomy, length of surgery, and bile leaks postoperatively were assessed. Results. Among 178 patients who underwent cholecystectomy, there were 40 grade one GBs, 90 grade two GBs, 26 grade three GBs, 16 grade four GBs, and six grade five GBs. With a conversion rate of 6.74%, eight patients underwent subtotal cholecystectomy. Among them, four patients were graded as 5th grade, two as 4th grade, and two as 3rd grade according to PGS system. Postoperative bile leak was seen in three patients among which two were grade five GBs and one was grade four. Preoperative WBC, conversion to open, subtotal cholecystectomy, length of surgery, and postoperative bile leak all significantly increased with increasing grades ( p < 0.05 ). Conclusion. PGS can be applied in patients undergoing laparoscopic cholecystectomy in the rural setting of a developing nation. With its application, postoperative course could be predicted and adequate counselling can be done about the possibilities of the outcome.

Application of the parkland grading scale in video laparoscopic cholecystectomies

“…In a recent published study, Baral et al (13) used the Parkland grading scale in a rural community of a developing country and found a significant increase of conversion to open cholecystectomy and longer surgical times which is consisten with our study. However, they also found an association with postoperative biliary leak with greater grades on the Parkland grading scale.…”

Caracterización de la flora bacteriana en los pacientes con colelitiasis y colecistitis atendidos en un centro hospitalario de alta complejidad

“…Por otro lado, la clasificación Parkland es usada por parte del equipo de cirujanos para definir el pronóstico y la severidad de la enfermedad vesicular, así como sus posibles complicaciones intra y postoperatorias 17 . Para nuestra población la clasificación más frecuentemente encontrada fue grado 5, contrario a lo reportado por Baral, Chhetri y Thapa en su estudio realizado en Palpa, Nepal, en el que de una muestra de 178 pacientes la clasificación más frecuente fue la de Parkland grado 2, con un 50,5 % de los pacientes, lo que puede indicar que en nuestra población las colecistectomías llevadas a cabo suelen tener un grado de complejidad mayor y son susceptibles de sufrir mayores complicaciones intraoperatorias y postoperatorias 18 .…”

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“…Baral et al (13) en un estudio reciente publicado utilizaron la escala de Parkland en una comunidad rural de un país en vías de desarrollo y encontraron un aumento significativo de conversión a colecistectomía abierta y duración de la cirugía lo que coincide con nuestro estudio, sin embargo, también encontraron asociación con fuga biliar postoperatoria con mayores grados de la escala de Parkland. En nuestra serie tuvimos solo un caso de fuga biliar postoperatoria diagnosticada, que requirió reintervención y fue un caso Grado I en la Escala de Parkland.…”