Comment on Preoperative prediction of difficult laparoscopic cholecystectomy.

This correspondence evaluates the study by Basukala et al on the preoperative prediction of difficult laparoscopic cholecystectomy (LC). While the authors contribute to an important area of surgical risk stratification, several methodological considerations may limit the robustness and clinical applicability of their model. Notably, key determinants of operative difficulty, including the timing of intervention, were not incorporated, despite strong support from guidelines and prior evidence. In addition, the study does not clearly distinguish between preoperative predictive variables and intraoperative outcome measures, such as the Nassar grading system, which may affect the validity of the model. Further concerns include the omission of well-established predictors of difficult LC, including prior abdominal surgery, obesity, comorbidities, inflammatory markers, male sex, and advanced age. The model's emphasis on high sensitivity without adequate consideration of specificity also raises questions regarding its practical utility, as this imbalance may lead to an overestimation of case complexity. Moreover, the exclusion of clinically relevant variables, such as body mass index, alongside the absence of methodological safeguards like blinding, limits generalizability compared to other contemporary models.