From grading to guidelines: recommendations for safe laparoscopic cholecystectomy based on the Parkland grading system

Abstract

Background: Laparoscopic cholecystectomy is one of the most studied laparoscopic surgeries. Recently parkland grading scale has added a simple intra-operative component to assessing difficulty of cholecystectomy. We aim to utilise this Parkland grading system for formulating recommendations on how to proceed in the surgery.

Methods: This was a retrospective study of recorded laparascopic cholecystectomies done at Max Hospital, Gurugram, Haryana. All the patients underwent laparoscopic cholecystectomy from October 2022 to March 2024. The Parkland grading scale (PGS) was noted at the start of the surgery and thereafter the progression of surgery was studied under various headings. All the pre-operative, intra-operative and post-operative findings were assessed to formulate recommendations for safe laparoscopic cholecystectomy.

Results: A total of 416 patients were graded utilizing PGS system. Out of 416 gall bladders graded, 127 (29.3%) were assessed to be grade 1, 146 (35.1%) were grade 2, 90 (21.6%)were grade 3, 34 (8.1%) were grade 4 and 24 (5.7%) were grade 5 as per PGS. When talking about any alteration to standard approach of doing a lap cholecystectomy, fundus first approach was the first change used by the operative surgeons. 32.2% of patients in PGS 3 had to be converted to fundus first approach, 61.7% of PGS 4 and 75% of PGS 5 patients had same surgical fate. Conversion to open cholecystectomy was also done in a small number of patients. Only 3 out of 34 and 4 out of 24 patients from PGS 4 and 5 respectively underwent this bailout procedure. Use of harmonic scalpel was used more frequently in higher grades of PGS as high as 95.8% patients in PGS 5 and 50% patients in PGS 4 and 11% in PGS 3. The use of hemolock for clipping of vessel and ducts was similar in occurrences 50% in PGS 5 and 35.2% in PGS 4, 5% in PGS 2, 8.8% in PGS 3. When studied about intra-op injuries, vascular injuries although low in number had a relative increased incidence with increasing parkland grade

Conclusion: PGS can be highly predictive for difficult cholecystectomy and every surgeon with or without adequate experience should be aware of potential complications. PGS grade 4 and higher have higher rate of conversion to fundus-first approach. PGS 4 and 5 had lesser complication rates and have shorter operative time if the decision to convert to a fundus first or open cholecystectomy was taken earlier. Planning appropriate line of further management without wasting much time is what we advocate. The author would like to stress upon the fact that no role of subtotal cholecystectomy was found in our study when timely decisions regarding change in approach was taken.