TPT 8.06 Male Sex Independently Predicts Severe Operative Difficulty (Nassar Grade IV–V) During Laparoscopic Cholecystectomy: A 31-Year Prospective Specialist Biliary Service Database Study

Abstract

Male sex is linked to conversion after laparoscopic cholecystectomy (LC); however, conversion is an imprecise surrogate for operative difficulty. We tested whether male sex predicts severe difficulty graded by the Nassar scale in a specialist biliary cohort. We analysed prospectively maintained database of LC with or without laparoscopic common bile duct exploration (LCBDE), 1992–2023. The cohort only included cases with recorded sex and Nassar grade; severe difficulty was grade IV–V. Multivariable logistic regression adjusted for clinical, imaging, and operative covariates (LCBDE and era); performance was summarised using AUC and Brier score. Among 6,129 procedures, 1,615 (26.3%) were male; men were older (median 57 vs 49 years) and more often emergency admissions (55.0% vs 44.1%) (both p<0.001). Severe difficulty occurred in 30.1% of men versus 12.8% of women (absolute difference 17.3%; unadjusted OR 2.93; p<0.001); grade IV–V comprised 1,065 cases (17.4%). Men had higher proportions of grade IV (26.1% vs 11.1%) and grade V difficulty (4.0% vs 1.7%). Male sex remained independently associated with severe difficulty (adjusted OR 1.90 (1.59–2.28); p<0.001); AUC was 0.859 and Brier score 0.105. Conversion was rare and did not differ by sex (0.62% vs 0.42%; p=0.299). Severe difficulty stratified outcomes: operative time 105 vs 55 min, stay 8 vs 3 days, conversion 1.9% vs 0.2%, and complications 14.5% vs 5.6% (all p<0.001). Male sex independently predicted severe intra-operative difficulty (Nassar IV–V). Incorporating sex into preoperative stratification may support list planning, senior support, and anticipatory bail-out strategy selection.