The treatment of choice for the management of symptomatic gall stone disease is laparoscopic cholecystectomy, one of the most frequently performed surgical operations worldwide [1]. Due to the challenging geographic variety of the rural population who come to our centre for healthcare and their lack of understanding of the illness process, late presentation for medical care frequently results in difficulty in surgery with an elevated risk of complications and conversion. In order to grade the complexity of surgery for patients having cholecystectomy for cholecystitis, many preoperative grading measures have been created. These scores are entirely based on clinical factors and diagnostic modalities that primarily represent the intraoperative and postoperative results.

However, because of the complicated and ambiguous anatomical, clinical and histological characteristics, these grading systems have not been verified in a developing nation like India. Similar to this, only a few criteria, including the Parkland grading scale (PGS), have been adequately examined for intraoperative assessment of anatomical condition and inflammation of the gall bladder.

PGS is a five-tiered, readily implementable grading system that is based on the structure of the gall bladder and the inflammatory alterations brought on by the disease's ongoing inflammatory processes [2]. Our goal was to use this guideline and apply it to patients having laparoscopic cholecystectomy in a tertiary care center of a developing country with limited resources. We believe that this grading system, when used in everyday practise, enables us to forecast potential surgical outcomes, counsel the attendings and perhaps convert patients early while maintaining a low level of perseverance during laparoscopic operations.  

The patients who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis were included in this prospective cross-sectional study, which was done over a six-month period from March 2022 to September 2022 in a tertiary hospital in south India. Institutional Review Committee was consulted for ethical approval. PGs was applied and Preoperative white blood cell count, open conversion, subtotal cholecystectomy, length of surgery and postoperative bile leakage were all analyzed as outcome variables. It was expected that the aforementioned factors would rise as the disease's severity, which could be defined by an increase in the severity grade, did as well.

While the author himself performed the PGS categorization, two surgeons who have performed at least 500 laparoscopic cholecystectomies were in charge of the procedure. Since there were no laparoscopic facilities accessible at night, all procedures were elective, with acute cases having to wait a maximum of 12 hours to be operated on the following morning. The Parkland Grading System (PGS) is a five-tiered grading system created by Parkland Memorial Hospital in Texas, USA, in 2017. It is based on the idea of having: 

• A limited number of grades

• Being simple to remember

• Having consistent assignment among users using the anatomical and inflammatory aspects of the disease process [2]

The PGS grade for cholecystitis is displayed in Table 1 [3].

At our facility, the laparoscopic cholecystectomy was performed using four ports: an umbilical port for the camera, an epigastric port and two lateral 5mm ports. The umbilical port was made using the Hasson open method and the operating surgeon himself allocated each patient according to their PGS. The screen picture that was seen when the gall bladder was grabbed and retracted cephalad was deemed the first view for readily visualised gall bladders.

The initial image in patients with considerable inflammation and an unvisualized gall bladder was referred to as the view of the inflamed region. A unique pro forma with PGS cholecystitis severity criteria was created and completed by the operative surgeon. In the pro forma, factors such the patient's age, gender, subtotal cholecystectomy, open conversion and complications like postoperative bile leak within two months and wound infections were considered for both pre- and postoperative considerations. A p-value less than 0.05 was deemed significant in the statistical analysis, which was conducted using SPSS version 16. The Tukey-Kramer test was employed for all pairwise comparisons of means between grades and the Welch's one-way ANOVA was performed to assess the connection between the PGS for cholecystitis and the continuous outcomes of length of hospital stay.

Table 1: Parkland Grading Scale for Cholecystitis

The research included 60 patients in total, of whom 46 were female and 14 were male. Males were 51.13 12.72 years old on average, compared to 44.41 15.47 for females. There were 22 GBs in grade 1, 29 GBs in grade 2, 05 GBs in grade 3, 03 GBs in grade 4 and 1 GBs in grade 5. AST was 29:72 25:50 units/L and ALT was 30:06 32:82 units/L on average. Haemoglobin concentration was 12:52 1:19 g/dL on average. Grade 5 PGS had the thickest gall bladder wall, but only 1 patients had pericholecystic collection on ultrasound. (Table 2) Similar to this, there were 13 people with type 2 diabetes who converted, with 3 of them.

The relationship between the grade of the gallbladder after surgery and other surgical factors, such as subtotal cholecystectomy, conversion, postoperative bile leak and preoperative white cell count, is shown in Table 3. Three individuals received subtotal cholecystectomy compared to one patients who underwent open conversion, with a conversion percentage of 1.67%. According to the PGS system, among them, two received grades of third grade and one received grades of fourth grade. one patient, one grade four GBs, had postoperative bile leaks. The preoperative white cell count rose when the Parkland grade levelled down.

Gradually rising grades were substantially correlated with subtotal cholecystectomy, conversion to open surgery, postoperative bile leak and preoperative WBC.

Similarly, the Welch one-way ANOVA was used to evaluate the relation between the Parkland grading scale for cholecystitis and continuous outcome of length of surgery which was statistically significant (p = 0:0001). The Tukey–Kramer test for all pairwise comparisons (p <0:05) revealed Grade 1 significantly different from Grade 5, Grade 2 from 5, Grade 3 from 5, Grade 4 from 5 and Grade 5 from 1, 2, 3 and 4.

Table 2: Patient Perioperative Characteristics

Table 3: Association of Perioperative Gall Bladder Grade with Other Surgical Parameters

The conversion and surgical results are largely determined by anatomical heterogeneity and inflammatory variables [2-4]. Due to challenging geographic diversity and ignorance of the disease process, patients present for treatment later than necessary. By the time the treating surgeon notices them, the window of opportunity for treatment has already passed and the course of treatment may change.

Numerous preoperative grading risk factor criteria have been developed and validated to date, but only a small number of these scales, such as those by Randhawa et al. and others, take intraoperative variables into account [5–11]. Due to their complexity and recall difficulties due to the high number of variables they include, such grading systems have not yet found a place in routine clinical activities [3]. They also do not allow for accurate outcome comparisons. Additionally, it would seem logical for intraoperative scales to take outcomes comparisons into account rather than preoperative grades with which an immediate decision could be made intraoperatively, such as conversion or the taking over of the surgery by an experienced surgeon, which lowers the risk of complications [12].

The following assessment research on the usefulness of PGS has certain limitations, including a small sample size and just one institutional study. Although the majority of cases were rated by only two surgeons graded the intraoperative first view image. This suggests that there may be subjectivity in the assessments if they were performed by more surgeons and bias may exist when interobserver variability has not been assessed. More such assessments and validation investigations, combined with data from several locations, might genuinely outline the PGS grade's potential and confirm its dependability and global application.

Patients having laparoscopic cholecystectomy in a rural environment in a developing country can use PGS. With its use, the postoperative course could be predicted and proper counselling regarding the outcomes could be provided.

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