Association between Body Mass Index and Operative Difficulty in Laparoscopic Cholecystectomy

Abstract

Background: Symptomatic gallstone disease and related benign gallbladder disease is a condition that is surgically treated with laparoscopic cholecystectomy. But there are several anatomical, inflammatory and patient-related factors which may make them more or less difficult to operate on. Higher BMI may lead to technical difficulties in laparoscopic surgery including port placement, visibility, retraction, dissection and operative time. Objective: To determine the association between body mass index and operative difficulty in patients undergoing laparoscopic cholecystectomy. Methods: This descriptive cross-sectional study was conducted in the Department of Surgery, Lahore General Hospital, Lahore, Pakistan, from June 2025 to January 2026. The number of patients (N) was 75 those who had undergone laparoscopic cholecystectomy for symptomatic gallstone disease were included through non-probability consecutive sampling technique. The BMI was determined by measured height and weight and patients were classified as normal BMI, overweight, and obese. Intraoperative parameters such as port placement difficulty, dense adhesions, difficulty with dissection of Calot's triangle, blood loss, perforation of gall bladder, spillage of bile, requirement of additional port, conversion to open surgery and operative time were used to assess operative difficulty. SPSS software (version 26) was used to analyze data. The data were statistically analysed by chi-square test and one-way ANOVA where appropriate and the significance level set at <0.05. Results: Among 75 patients, the mean age was 43.6 ± 12.8 years, and the majority were female 49 (65.3%). The mean BMI was 27.8 ± 4.6 kg/m². Normal BMI was observed in 21 (28.0%) patients, overweight in 34 (45.3%), and obesity in 20 (26.7%). Operative difficulty increased with BMI. Difficult surgery was recorded in 2 (9.5%) normal-BMI patients, 7 (20.6%) overweight patients, and 7 (35.0%) obese patients, showing a statistically significant association between BMI and operative difficulty (p = 0.032). Mean operative time also increased significantly across BMI groups, from 42.8 ± 9.6 minutes in normal-BMI patients to 63.7 ± 14.8 minutes in obese patients (p < 0.001). Conclusion: Increased body mass index was significantly associated with greater operative difficulty during laparoscopic cholecystectomy. Obese patients had longer operative time and higher frequencies of difficult port placement, dense adhesions, difficult Calot’s triangle dissection, gallbladder perforation, additional port requirement, and conversion to open surgery. BMI should therefore be considered during preoperative assessment and operative planning.