G10 Scoring System for Laparoscopic Cholecystectomy
The G10 score is a 10-point intraoperative grading system that assesses gallbladder operative difficulty during laparoscopic cholecystectomy and predicts the likelihood of conversion to open surgery. 1, 2
Scoring Components and Classification
The G10 system evaluates 10 key operative parameters encountered during surgery 1, 2:
- Gallbladder appearance - including whether the gallbladder is completely buried 1
- Gallbladder distension - degree of tension and size 2
- Ease of access to the surgical field 2
- Presence of impacted stones in the gallbladder neck or cystic duct 1
- Free bile or pus outside the gallbladder - indicating perforation or severe inflammation 1, 3
- Presence of fistula - cholecystoenteric or other connections 1, 3
- Time required to identify cystic duct and artery 2
- Potential for biliary complications 2
Difficulty Stratification
Surgery is classified into four difficulty levels based on the total G10 score 1, 2, 3:
- Easy: G10 score < 2 1, 3
- Moderate: G10 score 2-4 1, 3
- Difficult: G10 score 5-7 1, 3
- Extreme: G10 score 8-10 1, 3
Predictive Value for Conversion
The G10 score demonstrates strong predictive ability for conversion from laparoscopic to open cholecystectomy 1:
- Mean G10 score for completed laparoscopic cases: 2.1-2.98 1, 3
- Mean G10 score for converted cases: 3.71-4.65 1, 3
- Conversion rate reaches 27.7-33% when G10 score ≥5 1, 3
- The optimal cutoff for predicting conversion is a G10 score of 3-4 1, 3
- Area under ROC curve: 0.772-0.79, indicating good discriminatory ability 1, 3
Most Significant Risk Factors
Four intraoperative variables are statistically most predictive of conversion 1, 3:
- Completely buried gallbladder - obscured by surrounding tissues 1
- Impacted stone - lodged in neck or cystic duct 1
- Free bile or pus outside gallbladder (OR 5.1) - strongest independent predictor 1, 3
- Presence of fistula (OR 15.8) - most powerful predictor when present 3
Clinical Applications
The G10 system serves multiple practical purposes in surgical practice 1, 2:
- Standardizes communication about operative difficulty between surgeons globally 1, 2
- Provides benchmarks for comparing outcomes across institutions and countries 1, 2
- Assists in surgical planning by identifying cases requiring experienced surgeons 2
- Facilitates research by creating uniform difficulty classifications for clinical studies 1, 2
- Improves patient counseling regarding realistic expectations for operative complexity 2
Validation and Performance
The G10 system has been validated in multinational, multicenter studies 1:
- Tested across 504 patients in 16 countries by 55 surgeons 1
- Sensitivity and specificity demonstrate reliable prediction of difficult cases 1
- The system shows consistent performance across both elective (56%) and emergency settings 1
- Mean operative time correlates with increasing G10 scores 1
Important Caveats
The G10 score is an intraoperative assessment tool, not a preoperative predictor 1, 2. This distinguishes it from preoperative scoring systems that use clinical and imaging findings 4, 5. The score is assigned during surgery based on actual operative findings, making it useful for real-time decision-making about conversion and for retrospective analysis of surgical difficulty 1, 2.
Broader adaptation and validation are still needed to establish the G10 system as a universal standard for cholecystectomy grading 1, 3.