Published: 2022-10-28

Is the Parkland grading scale related to surgical difficulty in laparoscopic cholecystectomy?

Gloria Guzmán Arguello, Javier Benítez Beltran, Israelelias Hernández Cruz, José Sevilla Flores, Alexa Romero, Brenda García, Aristeo Paulina, Sebastian Gomez Pedroso, Geovanna Herrera, Yessica Castellanos


Background: Acute cholecystitis is one of the most frequent surgical pathologies, accounting for 6-11% of patients with symptomatic gallstone disease. The gold-standard treatment for this disease is laparoscopic cholecystectomy because the minimally invasive surgery significantly benefits the patient in terms of less pain and early recovery. The Parkland grading scale (PGS) is a grading system based solely on intraoperative images, which stratifies gallbladder inflammation in five degrees based on anatomy and gallbladder inflammation. This grading system is useful and helps predict the outcome of the surgery.

Methods: This study correlated the PGS with surgical difficulty based on factors such as open conversion and subtotal cholecystectomy. We included 105 patients in this study who, over a seven-month period, underwent a laparoscopic cholecystectomy and were graded by the PGS.

Results: We enrolled a total of 105 patients in our study, in which 74 patients were female and 31 were male. Of the 105 patients, 94 had a laparoscopic cholecystectomy, 3 underwent an open conversion (meaning the conversion rate was 2.9%), and 8 had a subtotal cholecystectomy (a rate of 7.6%).

Conclusions: The PGS is an easy and applicable grading scale for surgeons, and its application could help predict the complexity of gallbladder surgery and the outcomes of each patient. However, additional high-quality studies are needed to asses and validate this scale in patients with acute cholecystitis and determine its predictive value. We should also adjust this study depending on the surgeons’ level of expertise.



Acute cholecystitis, Parkland grading scale, Cholecystectomy

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Mohamed S, Ahmed Z, Mohammed AM. Anticipation of difficulty during laparoscopic cholecystectomy. Arch Surg Clin Res. 2020;4:24-8.

Wakabayashi G, Iwashita Y, Hibi T. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepato Biliary Pancreatic Sci. 2013;25:73-86.

Ansaloni L, Pisano M, Coccolini F. WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016;14:25.

Baral S, Chhetri RK, Thapa N. Utilization of an Intraoperative Grading Scale in Laparoscopic Cholecystectomy: A Nepalese Perspective. Gastroenterol Res Pract. 2020;2020:8954572.

Madni T, Leshika D, Minshall C. The Parkland grading scale for cholecystitis. Am J Surg. 2018;215: 625-30.

Bourikian S, Anand RJ, Aboutanos M, Wolfe LG, Ferrada P. Risk factors for acute gangrenous cholecystitis in emergency general surgery patients. Am J Surg. 2015;210:730-3.

Lee W, Jang JY, Cho JK. Does surgical difficulty relate to severity of acute cholecystitis? Validation of the parkland grading scale based on intraoperative findings. . Am J Surg. 2018;219:637-41.

Wakabayashi G, Iwashita Y, Hibi T. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25:73-86.

Tufo A, Pisano M, Ansaloni L. risk prediction in acute calculous cholecystitis: a systematic review and meta-analysis of prognostic factors and predictive models. J Laparoendosc Adv Surg Tech. 2021;31:41-53.

Strasberg SM, Pucci MJ, Brunt ML. Subtotal cholecystectomy-“fenestrating” vs “reconstituting” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg. 2016;222:89-96.

di Buono G, Romano G, Galia M. Difficult laparoscopic cholecystectomy and preoperative predictive factors. Scientific Reports. Sci Rep. 2021.

Coccolini F, Catena F, Pisano M. Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis. Int J Surg. 2015;18:196-204.

Csikesz N, Singla A, Murphy M. surgeon volume metrics in laparoscopic cholecystectomy. Digest Dis Sci. 2009;55:2398-405.

Özden S, Er S, Saylam B. Letter to prospective validation of the Parkland Grading Scale for cholecystitis. Am J Surg. 2019;218:445.

Vollmer CM, Callery MP. Biliary injury following laparoscopic cholecystectomy: why still a problem?. Gastroenterology. 2007;3:1039-41.

Kohga A, Suzuki K, Okumura T, Yamashita K, Isogaki J, Kawabe A, et al. Does preoperative MRCP imaging predict risk for conversion to subtotal cholecystectomy in patients with acute cholecystitis?. Surg Endosc. 2021;35:6717-23.

Khan SM, Emile SH, Barsom SH, Naqvi SAA, Khan MS. Accuracy of pre-operative parameters in predicting severe cholecystitis-A systematic review. Surgeon. 2021;19:219-25.

Ambe PC, Papadakis M, Zirngibl H. A proposal for a preoperative clinical scoring system for acute cholecystitis. J Surg Res. 2016;200:473-9.

Gupta N, Ranjan G, Arora MP. Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg. 2013;11:1002-6.

Nassar AHM, Hodson J, Ng HJ, Vohra RS, Katbeh T, Zino S, Griffiths EA. Study Group, West Midlands research collaborative. predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system. Surg Endosc. 2020;34:4549-61.

Kologlu M, Tutuncu T, Yuksek YN, Gozalan U, Daglar G, Kama NA. Using a risk score for conversion from laparoscopic to open cholecystectomy in resident training. Surgery. 2004;135:282-7.