Development and Validation of a Preoperative Risk Score for Difficult Laparoscopic Cholecystectomy: A Retrospective Study in Resource-Limited Settings

Background Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures worldwide. Yet, reliably identifying patients at high risk for intraoperative conversion or major complications preoperatively remains challenging. In this study, we investigated factors associated with difficult LC and developed and validated a simple preoperative scoring system to predict it. Patients and Methods: We conducted a single-center, retrospective cohort study at Ibb University Hospitals, Yemen. Data were extracted from records of 301 consecutive patients who underwent LC between April 2020 and November 2024. The primary outcome, "surgical difficulty," was a composite endpoint of conversion to open surgery or major intraoperative complications. Multivariable logistic regression was used to identify independent predictors and derive an integer-based risk score. Model performance was evaluated using the Area Under the Receiver Operating Characteristic Curve (AUC), calibration plots, and Decision Curve Analysis (DCA). Results Of 301 patients, 37 (12.3%) experienced difficult LC. Multivariable analysis identified three key predictors: right upper quadrant rigidity (adjusted OR 8.50, 95% CI 4.21–17.15; 2 points), impacted stone on ultrasound (aOR 7.24, 95% CI 3.10–16.90; 2 points), and prior acute cholecystitis (aOR 3.16, 95% CI 1.45–6.88; 1 point). This yielded a 5-point Chole-Risk Score with excellent discrimination (AUC 0.848, 95% CI 0.789–0.907). At the optimal cutoff of ≥ 3 points, sensitivity reached 73.7% and specificity 86.5%. Calibration was strong (Hosmer-Lemeshow p  = 0.612), and DCA showed superior clinical utility across a broad threshold range. Conclusion The Chole-Risk Score is a reliable, bedside-accessible tool for predicting difficulty in LC. In settings like Ibb, Yemen, where advanced preoperative imaging may be limited, this score allows for the identification of high-risk cases, facilitating early senior surgical involvement and improving patient safety.