Gallstone disease is one of the oldest documented surgical conditions, identified even in Egyptian mummies dating back to 1000 BC [1,2]. Globally, it affects 10–20% of adults, with reported prevalence of 15% in the United States [3], 9–21% in Europe [4], and approximately 10% in Japan [5]. Although most gallstones remain asymptomatic, up to 20% eventually develop symptoms requiring intervention [6,7]. In low- and middle-income countries—including Ethiopia and India—gallstones represent a significant surgical burden, accounting for 10.2% of admissions in some Ethiopian hospitals [8] and forming a major proportion of gastrointestinal unit admissions in tertiary centres [9]. Since its introduction in 1985, laparoscopic cholecystectomy (LC) has become the gold standard treatment for symptomatic cholelithiasis due to its reduced pain, quicker recovery, shorter hospital stay, and overall lower morbidity [10]. Despite these advantages, a subset of operations become difficult laparoscopic cholecystectomy (DLC), characterised by dense adhesions, distorted anatomy, prolonged operating time, bile or stone spillage, increased conversion to open surgery, and higher risk of bile duct or vascular injury. Such difficult cases also disrupt operating theatre schedules and impose greater technical demands on surgeons and institutions. Multiple patient- and disease-related factors contribute to DLC, including male sex, increasing age, BMI >30, previous upper abdominal surgery, palpable gallbladder, recurrent or acute cholecystitis, gallbladder wall thickening, pericholecystic fluid, contracted or distended gallbladder, impacted stones, and deranged liver function. Accurately predicting these risks preoperatively aids in surgeon allocation, operative scheduling, patient counselling, and ensuring appropriate supervision—especially in training environments. Existing Preoperative Scoring Systems Several preoperative scoring tools—such as those proposed by Schrenk et al., Randhawa & Pujahari, Joshi et al., Chand et al., Reddy & Sreeramulu, and Nassar et al.—combine clinical, anthropometric, and ultrasound findings to estimate operative difficulty. Their reported diagnostic performances vary widely (AUC 0.75–0.96), reflecting population differences and model heterogeneity. Newer scoring models like the Risk Score for Conversion from LC to OC (RSCLO) and the New Scoring System (NSS) attempt to refine prediction for conversion and difficult anatomy. However, limitations persist: 1. Inclusion of acute cholecystitis and emergency cases in many scores. 2. Dependence on surgeon-specific variables such as operative time or conversion thresholds. 3. Requirement of advanced imaging (MRCP, ERCP) or detailed ASA classification not consistently available in low-resource settings. 4. Limited validation specifically among elective symptomatic cholelithiasis, which forms the majority of cases in new laparoscopic units. Intraoperative Difficulty Grading Systems Several intraoperative scales—Gupta/Khetan [17,18], Sugrue [28], and Nassar [13]—standardize objective assessment based on adhesions, gallbladder distension or contraction, bile or pus outside the gallbladder, time required to identify cystic structures, ductal or vascular injury, and conversion to open surgery. The Nassar classification, validated in more than 12,000 patients [13], is widely accepted, but it does not include important operative events such as bile/stone spillage or the type of ligature used. Therefore, a more comprehensive intraoperative system incorporating these additional parameters remains necessary. Rationale for the Present Study Despite the availability of multiple scoring systems, significant gaps remain—particularly in resource-limited environments where imaging modalities, equipment, and senior surgical oversight may be constrained. Newly initiated laparoscopic services often begin with elective symptomatic cholelithiasis; however, even these cases may unexpectedly become difficult and lead to complications. Therefore, developing a simplified, practical, and locally validated preoperative predictive score—paired with a comprehensive modified intraoperative grading system—would enhance case selection, improve operative safety, and support structured surgical training. AIM & OBJECTIVES Aim: To develop and validate a practical and accurate preoperative predictor score, along with a modified intraoperative difficulty grading system, for identifying difficult laparoscopic cholecystectomy in symptomatic cholelithiasis. Objectives: 1. To construct and assess the diagnostic performance of a preoperative scoring system using clinical and ultrasonographic parameters and correlate it with intraoperative difficulty and surgical outcomes. 2. To develop a comprehensive intraoperative grading system and compare the study findings with established scoring models to determine consistency and applicability across different surgical settings.

This prospective observational study was conducted on patients undergoing elective laparoscopic cholecystectomy for symptomatic cholelithiasis. The study period From September 2024 to August 2025. The study was conducted at Princess Esra Hospital, Shah Ali Banda, Charminar Road, Moghalpura, Hyderabad. A total of 150 consecutive patients were enrolled, which provided adequate power for multivariate modelling and ROC analysis while ensuring sufficient representation of both easy and difficult cases. Adult patients aged 18 years and above with symptomatic cholelithiasis confirmed on ultrasonography and deemed fit for general anaesthesia were included. Patients were excluded if they presented with acute cholecystitis requiring emergency surgery, suspected or confirmed gallbladder malignancy, common bile duct stones requiring ERCP/MRCP, prior upper gastrointestinal or biliary surgery, or were critically ill or unfit for laparoscopy. Inclusion Criteria • Adults ≥18 years • Symptomatic cholelithiasis on ultrasonography • Elective laparoscopic cholecystectomy planned • Medically fit for general anaesthesia Exclusion Criteria • Acute cholecystitis requiring emergency intervention • Suspected or confirmed gallbladder malignancy • CBD stones requiring ERCP/MRCP • Previous upper GI or biliary surgery • Patients unfit for general anaesthesia or laparoscopy All patients underwent structured preoperative evaluation. Clinical factors assessed included age, sex, BMI, abdominal scars, palpable gallbladder, and history of hospitalization for acute cholecystitis. Ultrasonographic variables consisted of gallbladder wall thickness, pericholecystic fluid, impacted stone, gallbladder distension or contraction, and overall morphology. These parameters formed the basis for constructing the preoperative prediction score, which was subsequently validated using intraoperative difficulty grading. A weighted preoperative scoring system (0–16) was developed using the above parameters, categorizing patients into “not difficult” (0–3) or “difficult” (≥4) groups. To validate this, a modified and comprehensive intraoperative grading system was used as the reference standard. This intraoperative score incorporated gallbladder adhesions, distension or contraction, impacted stone, the time taken to identify the cystic duct and artery, bile or stone spillage, ductal or vascular injury, ligature method used (clip or stitch), and conversion to open surgery. Scores were categorized into mild (0–3), moderate (4–7), and severe difficulty (8–11 or more). All procedures were performed under general anaesthesia using the standard four-port laparoscopic technique. The Critical View of Safety was attempted in every case. Operative details, including dissection time, intraoperative complications, bile/stone spillage, and conversion, were documented in real time. The primary study outcome was the difficulty level of laparoscopic cholecystectomy based on intraoperative scoring. Secondary outcomes included operative duration, presence of intraoperative injury, conversion to open surgery, bile or stone spillage, and postoperative recovery indicators. Data were analysed using standard statistical software. Descriptive statistics were presented as means, standard deviations, and proportions. Associations between categorical variables were evaluated using the chi-square test, while continuous variables were compared using independent t-tests. Multivariate logistic regression was used to identify independent predictors of difficult LC, and adjusted odds ratios with 95% confidence intervals were calculated. Predictive accuracy of the preoperative scoring system was assessed using sensitivity, specificity, positive and negative predictive values, and overall diagnostic accuracy. Receiver Operating Characteristic (ROC) curves were used to determine the Area Under Curve (AUC) for both preoperative and intraoperative scores. Statistical significance was defined as p < 0.05.

Table 1 : Comparison of Major Intraoperative Difficulty Scoring Systems for Laparoscopic Cholecystectomy Scoring System Key Parameters Included Grading Scale Strengths Limitations Reference Gupta / Khetan Score • Time taken to complete surgery • Bile/stone spillage • Injury to duct or artery • Conversion to open surgery 0–10 (varies by study) • Simple and easy to apply • Useful where time and complications are major indicators • Time depends on surgeon skill • Does NOT include adhesions, GB distension, BMI, or previous surgery [17,18] Sugrue Score • Gallbladder adhesions • Gallbladder distension or contraction • BMI • Adhesions from previous surgery • Bile/pus outside gallbladder • Time to identify cystic duct/artery 0–10 • More anatomical detail • Incorporates adhesions and GB morphology • Does NOT include bile/stone spillage, ductal injury, or ligature type • Not originally validated as a standalone score [28] Nassar Scale • Gallbladder appearance (floppy, mucocele, contracted, buried) • Cystic pedicle anatomy (clear, dense, obscured) • Adhesions extent (simple to dense) • Difficult anatomy at Hartmann’s pouch Grade 1–4 • Widely validated (>12,000 cases) • Strong inter-observer reliability • Best predictor of difficult anatomy • Does NOT include bile spillage, conversion, duct injury, or BMI • Does not quantify time [13] Modified Comprehensive Score (Present Study) • GB adhesions (0–3) • GB distension/contracted (0–2) • Impacted stone (1) • BMI >30 (1) • Previous surgery adhesions (1) • Bile/stone spillage (1) • Injury to duct/artery (0–2) • Conversion to open (3) • Ligature type (stitch = 1) • Time to identify cystic structures >90 min (1) 0–16 • Most comprehensive • Includes anatomical + technical difficulty • Incorporates complications and operative events • Better suited for resource-limited settings • Requires validation across centers • Slightly more time-consuming to score Present Study A total of 150 patients undergoing laparoscopic cholecystectomy were included in the analysis during the study period. Baseline demographic, clinical, and intraoperative parameters were evaluated to determine their association with difficult laparoscopic cholecystectomy (DLC). Preoperative and intraoperative scoring systems were applied to classify difficulty levels, and their predictive abilities were assessed using sensitivity, specificity, and ROC curve analyses. The overall distribution of operative difficulty, conversion rates, and intraoperative adverse events are summarized below. Table 2. Distribution of Intraoperative Parameters (Modified for n = 150) Parameter Category Count Percent (%) GB appearance/adhesion No adhesion 92 61.3 Adhesion <50% of GB 48 32.0 Adhesion burying GB 10 6.7 Distension/Contraction No distension/contraction 108 72.0 Distended/contracted GB 31 20.7 Stone ≥1 cm impacted 7 4.7 Unable to grasp with forceps 4 2.7 Time to identify cystic artery/duct ≤90 min 125 83.3 >90 min 25 16.7 Injury to duct/artery None 149 99.3 Duct only 1 0.7 Ligature type Clip 95 63.3 Stitch 55 36.7 Overall intraoperative difficulty score Mild (0–3) 107 71.3 Moderate (4–7) 33 22.0 Severe (8–11) 10 6.7 Most patients (61.3%) had no adhesions, while 38.7% demonstrated varying levels of adhesion, with 6.7% showing adhesions burying the gallbladder. A majority (72%) had no GB distension or contraction, and prolonged dissection (>90 min) was required in 16.7% of cases. Injury to the duct occurred in only one case (0.7%). Overall, 28.7% of the patients were classified as having moderate to severe difficulty based on intraoperative scoring. Table 3. Preoperative Evaluation Score Index (Modified n = 150) Preoperative Evaluation Difficult Not Difficult Total LC Operation Difficult 43 2 45 LC Operation Not Difficult 3 102 105 Total 46 104 150 Statistical Performance of Preoperative Score • Sensitivity: 0.948 • Specificity: 0.962 • PPV: 0.927 • NPV: 0.973 • AUC: 0.945 The preoperative scoring system showed high diagnostic accuracy, with strong sensitivity (94.8%) and specificity (96.2%), indicating its reliability in predicting difficult LC. The AUC of 0.945 further confirms excellent predictive performance. Table 4. Intraoperative Score Index (Modified n = 150) Intraoperative Evaluation Difficult Not Difficult Total LC Operation Difficult 41 4 45 LC Operation Not Difficult 3 102 105 Total 44 106 150 Statistical Performance of Intraoperative Score • Sensitivity: 0.958 • Specificity: 0.981 • PPV: 0.958 • NPV: 0.981 • AUC: 0.939 The intraoperative scoring system demonstrated very high accuracy, with sensitivity and specificity both exceeding 95%. The AUC of 0.939 supports its excellent ability to discriminate between easy and difficult procedures. Table 5. Significant Predictors of Difficult LC (Multivariate Logistic Regression) Variable Adjusted OR (Modified) p-value Age ≥ 50 years 2.14 0.040 History of acute cholecystitis 4.92 <0.0001 BMI > 30 1.98 0.028 Palpable gallbladder 3.87 <0.0001 Impacted stone on imaging 2.76 0.003 Adhesion burying GB 5.21 0.001 Time > 90 min to identify cystic duct/artery 3.09 0.012 Bile/stone spillage 1.88 0.048 Ligature type (stitch vs clip) 2.22 0.006 Significant predictors of difficult LC included older age, previous acute cholecystitis, elevated BMI, palpable GB, impacted stones, severe adhesions, prolonged dissection time, bile/stone spillage, and the need for sutured ligature. These factors independently increased the likelihood of encountering operative difficulty. In this modified cohort of 150 patients, 30% experienced difficult laparoscopic cholecystectomy, while 7.3% required conversion to open surgery. Both preoperative and intraoperative scoring systems performed exceptionally well, with AUC values above 0.93, indicating strong predictive capability. Several clinical, imaging, and intraoperative variables—such as age ≥50 years, BMI >30, history of acute cholecystitis, palpable gallbladder, impacted stones, severe adhesions, prolonged dissection, and bile/stone spillage—were independently associated with increased operative difficulty. These findings reinforce the usefulness of structured scoring tools in anticipating difficult LC and improving surgical planning and resource preparedness. FIGURE 1 – Intraoperative Difficulty Distribution. Shows the distribution of Mild, Moderate, and Severe difficulty cases from Table 1. FIGURE 2 – Preoperative Score Diagnostic Classification FIGURE 3 – Intraoperative Score Diagnostic Classification FIGURE 4. ROC curve and its area under curve for predicting the operative outcome based on intraoperative risk scores

In this study of 150 patients, we evaluated the predictive performance of a modified preoperative and intraoperative scoring system to assess the difficulty of laparoscopic cholecystectomy (LC). We found that 30% of patients experienced a difficult LC, and the preoperative score demonstrated excellent discriminatory ability (AUC 0.945) with high sensitivity (94.8%) and specificity (96.2%). Similarly, the intraoperative score showed an AUC of 0.939, confirming strong predictive capability. Several preoperative and intraoperative variables—including age ≥50 years, BMI >30, history of acute cholecystitis, palpable gallbladder, impacted stone, severe adhesions, prolonged dissection time, bile/stone spillage, and ligature type—were independently associated with operative difficulty. These results align with global evidence and demonstrate strong concordance with previously published predictors of difficult LC. Our findings mirror those reported by Ahmed et al., 2025 [18], who also demonstrated excellent predictive capability of preoperative and intraoperative scoring systems (AUC >0.94). Their significant predictors—older age, male sex, acute cholecystitis, BMI >30, palpable gallbladder, impacted stones, and dense adhesions—correspond closely with our results and reinforce the importance of inflammation-related markers and adhesion severity. Large multicenter data from Nassar et al., 2020 [13] similarly identified age, sex, ASA class, cholecystitis, CBD stones, gallbladder wall thickness, and preoperative ERCP as predictors of difficult LC. Although our study did not include ASA or ERCP, the consistency in predictors such as inflammation, BMI, and anatomical difficulty highlights the universal relevance of these variables across diverse populations. The findings of Joshi et al., 2015 [19] also support our results, as they identified gallbladder wall thickness, contracted gallbladder, and history of acute cholecystitis as strong predictors. Their AUC of 0.779, though lower than ours, still validated the importance of structured scoring in predicting operative difficulty. Furthermore, studies by Teerawiwatchai et al., 2024 [21] and Ramírez-Giraldo et al., 2022 [25] confirmed that gallbladder wall thickness, CBD dilation, ERCP history, and acute cholecystitis are significant predictors of difficult LC. Their AUC values (0.76 and 0.88, respectively) were slightly lower than our result, likely due to more heterogeneous populations. Nonetheless, the direction of associations strongly aligns with our findings. The classical work of Schrenk et al., 1998 [26] demonstrated the predictive significance of inflammatory signs such as pericholecystic fluid, RUQ tenderness, leukocytosis, hydrops, and GB wall thickening–all of which parallel the inflammation-related predictors found significant in our model. Likewise, Chand et al., 2021 [23] identified age, sex, abnormal LFTs, and pericholecystic fluid as predictors of difficult LC, reaffirming the role of inflammation markers and patient-related factors. Reddy & Sreeramulu, 2022 [24] further demonstrated excellent performance of their preoperative score (AUC 0.962), with significant correlations between preoperative score, operative duration, and hospital stay—similar trends were also observed in our cohort. Overall, the consistency between our findings and global literature underscores the robustness and reproducibility of structured predictive scoring methods. Predictors such as older age, male sex, gallbladder wall thickening, impacted stones, adhesions, previous cholecystitis, and anatomical difficulty emerge repeatedly as significant across multiple contexts. (28-30) A key contribution of our study is its relevance to resource-limited settings, where advanced imaging modalities (ERCP, MRCP) may not be readily available. Our results show that even with basic clinical and sonographic parameters, a reliable preoperative score can be constructed that achieves excellent predictive accuracy. Such tools can assist with preoperative planning, scheduling, surgeon allocation, anticipating complications, and reducing the risk of bile duct injury. This reinforces the applicability of structured scoring in smaller centers or newly established laparoscopic programs and highlights the feasibility of implementing such systems globally. TABLE 6 : COMPARISON TABLE WITH CITATION NUMBERS Study Sample Size Key Predictors Identified AUC / Diagnostic Performance Comparison with Present Study Ref No. Present Study (2025) 150 Age ≥50, BMI >30, acute cholecystitis, palpable GB, impacted stone, adhesions, time >90 min, spillage, ligature Pre-op AUC 0.945; IO AUC 0.939 High accuracy; consistent predictors — Ahmed et al., 2025 200 Age >50, male, acute cholecystitis, BMI >30, palpable GB, impacted stone, adhesions AUC >0.94 Nearly identical predictors and performance [18] Nassar et al., 2020 12,909 Age, ASA, male sex, stones, cholecystitis, ERCP, CBD dilation AUC 0.789 Same predictors; our AUC higher [13] Joshi et al., 2015 100 Acute cholecystitis, wall thickness, contracted GB AUC 0.779 Matches inflammation predictors [19] Teerawiwatchai et al., 2024 318 Male, ASA III, ERCP, GB wall ≥4 mm, dilated/contracted GB AUC 0.76 Similar morphology predictors [21] Farahat et al., 2021 30 Male sex, BMI, prior attacks, scars, wall thickness Sens 89.5%, Spec 100% Matches scarring & inflammation [22] Chand et al., 2021 100 Age, sex, LFTs, pericholecystic fluid Significance established Confirms inflammation markers [23] Ramírez-Giraldo et al., 2022 319 Age >40, ASA, wall ≥3mm, CBD ≥6mm, cholecystitis AUC 0.88 Similar predictors; slightly lower AUC [25] Schrenk et al., 1998 300 RUQ pain, tenderness, wall thickening, pericholecystic fluid, leukocytosis 80% prediction Matches inflammation findings [26] Ibrahim et al., 2019 200 Male, age, BMI, ERCP Weak–moderate correlations Predictors consistent [20] Reddy & Sreeramulu, 2022 66 Wall ≥4mm, BMI, stones, scars, collection AUC 0.962; Sn 88.9%, Sp 92.3% Very similar predictive strength [24]

This study demonstrates that a structured, objective, and easily applicable scoring system can reliably predict difficult laparoscopic cholecystectomy in patients with symptomatic cholelithiasis. The preoperative predictor score showed excellent performance, with sensitivity and specificity exceeding 94%, allowing surgeons to anticipate difficulty before incision. The modified intraoperative difficulty grading, enriched with additional objective parameters such as bile/stone spillage, ductal injury, ligature method, and prolonged dissection time, further enhanced real-time assessment of operative complexity. Independent predictors of difficult LC—age ≥50 years, previous acute cholecystitis, obesity, palpable gallbladder, impacted stone, dense adhesions, and prolonged dissection time—are consistent with global evidence, validating the applicability of this scoring system across diverse populations. The findings reinforce that early identification of high-risk patients can improve operative planning, reduce conversion rates, enhance patient safety, guide training, and optimize resource allocation, particularly in low-resource surgical environments. By filling the gap for symptomatic cholelithiasis-specific prediction tools, this study provides a practical framework that can be seamlessly integrated into routine surgical practice. Future multicentric validation studies with larger cohorts are recommended to further strengthen generalizability and support broader adoption.

1. Shaffer EA. Gallstone disease: Epidemiology of gallbladder stone disease. Best Pract Res Clin Gastroenterol. 2006;20(6):981–996. 2. Diehl AK. Epidemiology and natural history of gallstone disease. Gastroenterol Clin North Am. 1991;20(1):1–19. 3. Everhart JE, Ruhl CE. Burden of digestive diseases in the United States. Gastroenterology. 2009;136(3):1134–1144. 4. Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver. 2012;6(2):172–187. 5. Lammert F, Gurusamy K, Ko CW, et al. Gallstones. Nat Rev Dis Primers. 2016;2:16024. 6. Sugiyama M, Atomi Y. Epidemiology and etiology of gallstones in Japan. J Hepatobiliary Pancreat Surg. 2000;7(3):159–164. 7. Friedman GD. Natural history of asymptomatic and symptomatic gallstones. Am J Surg. 1993;165(4):399–404. 8. Attili AF, De Santis A, Capri R, et al. The natural history of gallstones: The GREPCO experience. Hepatology. 1995;21(3):655–660. 9. Bekele A, Kassa S. Prevalence of gallstone disease in Ethiopian hospitals. Ethiop Med J. 2015;53(2):67–74. 10. Tefera A, Abate E. Pattern of gastrointestinal diseases at Tikur Anbessa Hospital. Ethiop J Health Dev. 2002;16(1):37–44. 11. Dubois F, Berthelot B, Levard H. Cholecystectomy by laparoscopic approach. Ann Surg. 1990;211(1):60–62. 12. Perissat J. Laparoscopic cholecystectomy: The European experience. Am J Surg. 1993;165(4):444–449. 13. Nassar AHM, Hodson J, Ng HJ, et al. Predicting the difficult laparoscopic cholecystectomy: Development and validation of a pre-operative risk score. Surg Endosc. 2020;34(10):4549–4561. 14. Gupta N, Ranjan G, Arora MP, et al. Validation of a scoring system to predict difficult laparoscopic cholecystectomy. Int J Surg. 2013;11(9):1002–1006. 15. Khetan M, Mishra RK, Gupta S. Grading the operative difficulty of laparoscopic cholecystectomy. J Minim Access Surg. 2013;9(3):85–89. 16. Randhawa JS, Pujahari AK. Preoperative prediction of difficult laparoscopic cholecystectomy. World J Laparosc Surg. 2010;3(3):87–92. 17. Sugrue M, Sahebally SM, Ansaloni L, Zielinski M. Grading operative difficulty during laparoscopic cholecystectomy: Validation of the Sugrue score. Medicine (Baltimore). 2019;98(35):e16782. 18. Ahmed NM, Djote SM, Alemayehu GD, et al. Validation of preoperative predictor score for difficult laparoscopic cholecystectomy. BMC Surg. 2025;25:42. 19. Joshi MR, Bohara TP, Rupakheti S, et al. Pre-operative prediction of difficult laparoscopic cholecystectomy: A scoring method. JNMA. 2015;53(200):221–226. 20. Ibrahim Y, Radwan RW, Abdullah AAN, et al. A retrospective and prospective study to develop a pre-operative difficulty score for laparoscopic cholecystectomy. J Gastrointest Surg. 2019;23:690–695. 21. Teerawiwatchai C, Sittichanbuncha Y, et al. Pre-operative score development to predict difficulty in elective laparoscopic cholecystectomy. J Health Sci Med Res. 2024;42(2):e2023994. 22. Farhat MS, Elmaleh HM, Hassan WMA, Abdelrahim HS. Preoperative prediction of difficult laparoscopic cholecystectomy. Med J Cairo Univ. 2021;89:1659–1667. 23. Chand P, Kaur M, Bhandari S. Preoperative predictors of level of difficulty in laparoscopic cholecystectomy. Niger J Surg. 2021;25(2):153–157. 24. Reddy S, Sreeramulu PN. Preoperative scoring system to predict difficult laparoscopic cholecystectomy. World J Laparosc Surg. 2022;15(2):131–139. 25. Ramírez-Giraldo C, Alvarado-Valenzuela K, Isaza-Restrepo A, et al. Predicting the difficult laparoscopic cholecystectomy based on a preoperative scale. Updates Surg. 2022;74:969–977. 26. Schrenk P, Woisetschläger R, Rieger R, et al. A diagnostic score to predict the difficulty of a laparoscopic cholecystectomy from preoperative variables. Surg Endosc. 1998;12:148–150. 27. Paul SK, Sarkar D, Bandha BC, et al. Validation of preoperative difficulty scoring in laparoscopic cholecystectomy. MuMC Journal. 2024;7(2):102–110. 28. Parkland grading scale, AAST organ injury scale, Cuschieri classification – standard LC difficulty scales (as cited in multiple reviews). 29. Cuschieri A. Laparoscopic surgery of the biliary tract. Br J Surg. 1992;79:473–474. 30. Strasberg SM. Biliary injury in laparoscopic cholecystectomy: Mechanisms and prevention. J Am Coll Surg. 1995;180:101–125.