What is the best score for predicting difficult laparoscopic cholecystectomy? A diagnostic trial study.

BACKGROUND: Multiple scores have been created in order to predict difficult cholecystectomy, nonetheless there is not a consensuated standard on which to use. The importance of a predictive score to be able to establish a difficult cholecystectomy would be a relevant instrument in order to better inform the patient, properly call for help when needed, choose the correct staff, and schedule and plan the surgical procedure accordingly. METHODS: A diagnostic trial study was performed. All different predictive scores for difficult cholecystectomy were calculated for each patient. The correlation between the preoperative score and cholecystectomies considered as "difficult" were measured estimating the preoperative score's predictive value using a receiver operating characteristics curve in order to predict findings for difficult cholecystectomy. RESULTS: A total of 635 patients between 2014 and 2021 were selected. Selected patients had a mean age of 55.0 (interquartile range: 28.00) and were mostly female (64.25%). Surgical outcomes of patients with difficult cholecystectomy had statistically significant higher rates of subtotal cholecystectomies, drain usage, complications and reinterventions, prolonged surgical times, and longer hospital stay. When analyzing the predictive value on each of the different scores applied, score 4 had the highest performance for predicting difficult cholecystectomy with an area under the curve=0.783 (CI 95% 0.745-0.822). CONCLUSIONS: Difficult cholecystectomies are associated with worse surgical outcomes. The standardization and use of predictive scores for difficult cholecystectomy must be implemented in order to improve surgical outcomes as a result of more meticulous planning when scheduling the procedure.

Left diaphragmatic hernia following thoracoabdominal aortic repair: A case report.

INTRODUCTION: Diaphragmatic hernias are somewhat rare complications of thoracoabdominal interventions. Given their late clinical manifestations and misdiagnosis, their incidence is unknown. These hernias have a high mortality risk when an emergency intervention is warranted due to complications from visceral strangulation. CASE PRESENTATION: We present the case of a 67-year-old male with prior history of thoracoabdominal aortic repair, who reconsults due to upper gastrointestinal bleeding. Upon arrival, imaging shows a left diaphragmatic herniation with migration of the stomach, omentum and spleen to the thoracic cavity. Through laparoscopic approach, a left diaphragmatic hernial defect is identified with protrusion of half the stomach, omentum and the posterior aspect of the spleen with a sub capsular tear. Additionally, a severe adhesion syndrome on the chest wall and diaphragm were also evident, with entrapment of the inferior lobe of the left lung. The contents were successfully reduced, however pulmonary decortication and extensive adhesiolysis through thoracoscopy was required for complete extraction, enabling a primary repair without tension. CONCLUSIONS: We present an infrequent pathology without an established incidence, which has relevant clinical and surgical implications at any level of care, in this case requiring interdisciplinary management. The suspicion of diaphragmatic hernia in a patient with past medical history of thoracoabdominal aortic repair with non-specific gastrointestinal symptoms is essential. We emphasize the importance of clinical suspicion of this complication once the surgical precedent has been identified.