Predictor Factors of Difficult Laparoscopic Cholecystectomy in Cholelithiasis Patients at Mohammad Hoesin Hospital, Palembang

Laparoscopic cholecystectomy is the gold standard for cholecystectomy and can be performed by trained general surgeons. However, the percentage of complications that occur from cholecystectomy laparotomy is approximately 20 percent. So, it is necessary to research risk factors for complications. This research is an analytic observational study with a cross-sectional design using preoperative data and intraoperative findings of laparoscopic cholecystectomy. Age, gender, body mass index, history of cholecystitis, number of stones, and location of stones are identified as predictors that affect the difficulty of laparoscopic cholecystectomy. The data collection was performed at the Mohammad Hoesin Hospital Palembang Department from July 2019July 2020. Of the 67 research samples, a Chi-square test was performed, and the factors that had a significant relationship were the body mass index (P-Value 0,000), history of cholecystitis (P-Value 0,000), number of stones (P-Value 0.049), and stone location. (P-Value 0.002). The backward stepwise logistic regression using the four variables showed that the history of cholecystitis had an independent effect (OR-adjusted 28.889 and P-Value 0.000).


Introduction
Gallstone disease (cholelithiasis) is one of the most common diseases of the digestive tract.
Limitation cholelithiasis is a disease of gallstones found in the gallbladder. It is estimated that there is a 10-15% incidence of gallstones in the adult population in the United States. 1 Approximately 1,000,000 operations are performed annually for this disease; at least 6,000 deaths occur as a result of complications and management. 2  With that, it is hoped that the morbidity and mortality rates can be reduced. 3 Some authors subsequently classified laparoscopic cholecystectomy as easy (operation time <60 minutes, no bile spillage, no injury to the ducts or arteries), and difficult (operation time> 60 minutes, bile/stone spillage, duct injury, and conversion to open cholecystectomy in approximately 2.6% -5.2% . [4][5] This study was conducted to identify the various factors associated with difficult laparoscopic cholecystectomy that can assist in predicting or anticipating difficult laparoscopic cholecystectomy in the pre-operative period, enabling the surgeon to prepare in advance for difficulties to be encountered during the procedure, thereby reducing morbidity and mortality from difficult laparoscopic cholecystectomy. Based on the background described above, the problem formulation in this study is

Methods
This research is an analytic observational study with a cross-sectional design, conducted at the Department of Surgery, Mohammad Hoesin Hospital, Palembang from July 2019-July 2020.
The total sample size of 67 patients was collected using a non-random method, namely, consecutive sampling.
The inclusion criteria were patients who had been diagnosed with cholelithiasis and patients with cholelithiasis who underwent laparoscopic cholecystectomy. The exclusion criteria were patients with CBD dilation, CBD stones, increased alkaline phosphatase, and requiring exploration of CBD, patients with obstructive jaundice, patients with suspicion of gallbladder malignancy.

Study Results and Discussion.
The research subjects were 67 people who had met the inclusion and exclusion criteria.
The gender of female 52.2% is slightly more than male 47.8%. Patients ≥65 years old were 16.4%, and patients <65 years were 56%. Body mass index ≥ 30 kg/m 2 was 25.4% and <30 kg/m 2 was 74.6%. For the history of cholecystitis 37.3% and intraoperative findings, the number of multiple stones was 88.1%, and impacted stones were 7.5%. For more details, see In this study, men (47.8%) were slightly less than women (52.2%). In the Chi-Square test, the P-value was 0.307, and the prevalence ratio was 0.564. Gender factors do not have a significant effect on difficult cholecystectomy laparoscopy.
There is an influence of gender on the process of gallbladder formation -more frequent inflammation and fibrosis -thus causing difficulties with laparoscopic cholecystectomy .28 Patient age was stratified by ≥65 years and <65 years. In this study, the age group ≥65 years (16.4%) and <65 years was 83%. In the Chi-square test, the P-value was 0.730, with a prevalence ratio of 1.311. in this study, the age factor had no effect on difficult laparoscopic cholecystectomy.
The patient's body mass index was categorized as obese (≥30 kg/m 2 ) and non-obese (<30 kg/m 2 ). There were 25.4% obese patients and 74.6% non-obese patients. In the Chi-Square test, the P-value was 0.000, and the prevalence ratio was 20.188. In this study, the Body Mass Index factor had a significant effect on Difficult Laparoscopic Cholecystectomy. Obesity is associated with a high incidence of complications in the biliary tract. This is caused by an abnormal distribution of fat, enlarged liver, and difficulty access and exposure. There is a morbidity triad, namely obesity, acute cholecystitis, and long operating time. 6 History of cholecystitis was 37.3%, and 62.7% were not. In the Chi-Square Test, the P- The location of impaction stones in the gallbladder was 7.5%, and the mobile was 92.5%.
In  giving an independent effect of (Adjusted Risk) 28.889 on difficult laparoscopic cholecystectomy.

Conclusion
In this study, it was found that there were slightly more women than men who suffered from cholelithiasis (age <65 years as much as 83.6%).
There is a correlation between body mass index, cholecystitis history, number of stones, and location of stones to difficult laparoscopic cholecystectomy. Variables History of cholecystitis was a factor that independently influenced adjusted risk (28.889) to difficult laparoscopic cholecystectomy.
It is necessary to do further research which involves more samples and more detailed and applicable variables so that the prediction of the laparoscopic cholecystectomy category can be used as a standard in Teaching Hospital.