Gender-based differences in laparoscopic cholecystectomy for gallbladder stones: A retrospective observational study

 Corresponding author: Asim Saad Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. Gender-based differences in laparoscopic cholecystectomy for gallbladder stones: A retrospective observational study Kanwal Fatima 1, Muhammad Afzal 2 and Asim Saad 3, * 1 Nursing Instructor, Aga Khan University. 2 Assistant Professor, CMH Kharian, Pakistan. 3 BS-Public Health, University of Karachi. World Journal of Advanced Research and Reviews, 2025, 27(02), 1372-1377 Publication history: Received on 10 July 2025; revised on 16 August 2025; accepted on 18 August 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.27.2.2973 Abstract Background: For gallbladder stones, laparoscopic cholecystectomy (LC) is the gold standard of care. There is little information on how gender affects clinical presentation, surgical results, and complication rates, despite the treatment being regarded as safe and minimally invasive. The purpose of this study was to assess and contrast perioperative factors in patients undergoing LC who were male and female. Methodology: 137 gallbladder stone patients who had LC at a tertiary care hospital were included in this retrospective observational analysis. Group A consisted of 40 male patients, while Group B included 97 female patients. Using proper statistical tests, baseline variables, intraoperative parameters, and postoperative outcomes were documented and compared. P-values less than 0.05 were regarded as statistically significant. Results: Between groups, the mean age and BMI were similar (p > 0.05). Hepatitis C positivity was more common in males (p = 0.001), although a considerably higher percentage of females had a history of prior abdominal operations (p = 0.01). Gallbladder morphology, conversion rates, blood loss, and operating time did not differ significantly. Most postoperative problems, including bleeding, wound infection, and bile leakage, did not differ substantially between the sexes. Male patients, however, experienced postoperative stomach distension considerably more frequently (p = 0.04). Conclusion: The safety and effectiveness characteristics of laparoscopic cholecystectomy are comparable for both sexes. Operative planning may be influenced by gender-specific characteristics, such as viral status and previous surgical history, even though surgical outcomes and complication rates are generally identical. Additional prospective research is required to validate these results. Keywords: Laparoscopic cholecystectomy; Gender differences; Gallbladder stones; Surgical outcomes; Postoperative complications 1. Introduction With an average prevalence of 10% to 20% in adults, cholelithiasis, also known as gallstone disease, is a common ailment worldwide, especially in industrialized and developing nations [1]. Due to its less invasive nature, shorter hospital stays, and fewer postoperative complications than open surgery, laparoscopic cholecystectomy (LC) has become the gold standard treatment for symptomatic gallstones [2]. There is a notable gender difference in the onset, progression, and surgical results of gallstone disease, according to numerous research. Estrogen-induced alterations in gallbladder motility and bile composition disproportionately impact females, especially those in their reproductive World Journal of Advanced Research and Reviews, 2025, 27(02), 1372-1377 1373 years [3]. On the other hand, while receiving fewer diagnoses, male patients frequently exhibit more complex disease states such acute cholecystitis or gallbladder empyema. This could be because they seek medical attention later or because they are not properly identified [4,5]. In addition, there are gender disparities in intraoperative variables such length of hospital stay, postoperative problems, conversion to open surgery, and operative time. Research indicates that male patients are more likely to undergo open cholecystectomy, have longer recovery periods, and experience more technical challenges during LC [6–8]. The data is nonetheless erratic and frequently population-specific in spite of these findings. After controlling for comorbidities and illness severity, some research suggest that gender should be regarded as an independent risk factor for problematic LC, while other studies find no significant correlation [9, 10]. Through a retrospective analysis of patient demographics, intraoperative parameters, and postoperative outcomes in a tertiary care context, this study seeks to assess gender-based disparities in laparoscopic cholecystectomy. Surgeons will have a better understanding of how gender plays a part in risk assessment, surgical planning, and patient counseling thanks to these findings. 2. Methodology The Department of General Surgery at a tertiary care teaching hospital in Pakistan, was the site of this retrospective observational study. All adult patients (age 18 - 75) who had a laparoscopic cholecystectomy (LC) for gallstone disease symptoms between January 2024 and March 2025 had their medical records examined. Before data collection, the Institutional Review Board granted ethical permission, and all data were anonymized to protect patient privacy. For the study, a minimum sample size of 127 was determined, using estimated prevalence of cholelithiasis reported as 9.03% in Pakistan, according to Naseem et al11. The distribution within groups was determined according to the gender of patients. The approach of successive sampling was used. Patients who received elective or emergency LC and had a verified gallstone diagnosis were included. Patients having a history of prior upper abdominal surgery to prevent confounding from adhesions, those with gallbladder malignancy, those with insufficient medical records, and those who had an initial open cholecystectomy without a laparoscopic attempt were all excluded. A structured data abstraction form was used to extract the data. Comorbid conditions (e.g., diabetes mellitus or hypertension), clinical history (duration of symptoms, prior episodes of cholecystitis), demographic information (age, sex, BMI), and intraoperative parameters (duration of surgery, presence of adhesions, intraoperative complications, conversion to open cholecystectomy) were among the variables gathered. Postoperative outcomes were also documented, including 30-day readmission rates, length of hospital stay, and postoperative complications (such as bile leak, surgical site infection, and fever). SPSS version 25 was used to enter and analyze all the data. The characteristics of the patients and the results of the surgery were summarized using descriptive statistics. For continuous variables, means and standard deviations were computed; for categorical data, frequencies and percentages were provided. Depending on the data distribution, continuous variables were compared between male and female patients using either the independent t-test or the Mann-Whitney U test. For categorical comparisons, Fisher's exact test or the chi-square test was employed. To identify gender as an independent predictor of difficult LC or adverse postoperative outcomes, multivariate logistic regression analysis was performed while adjusting for potential confounding factors, including age, BMI, and presence of comorbidities. P-values below 0.05 were regarded as statistically significant. 3. Results The study included 137 individuals who had laparoscopic cholecystectomy; 40 of these patients were male (Group A) and 97 were female (Group B). 3.1. Baseline characteristics The mean age of female patients was slightly higher at 51.2 ± 10.8 years, compared to 48.7 ± 14.1 years for male patients; however, the difference was not statistically significant (p = 0.091). Males and females had similar mean BMIs (26.1 ± 4.1 vs. 25.8 ± 2.7, respectively; p = 0.33) The history of prior abdominal surgeries showed a statistically significant difference, with female patients having a higher frequency of this difference (48 vs. 4; p = 0.01). Only male patients (2 males vs. 0 females) tested positive for World Journal of Advanced Research and Reviews, 2025, 27(02), 1372-1377 1374 hepatitis C, and this difference was statistically significant (p = 0.001). Regarding the existence of comorbidities, there was no discernible difference between the groups (p = 0.14). Table 1 Demographic details and baseline characteristics of study participants. Group A Group B P-value N=40 Male patients N= 97 Female patients Age (mean ± st. dev) 48.7 ± 14.1 51.2 ± 10.8 0.091 BMI (mean ± st. dev) 26.1 ± 4.1 25.8 ± 2.7 0.33 Abdominal surgery Hx 4 48 0.01 Comorbidities 9 24 0.14 Hep C +ve 2 0 0.001 3.2. Results of Intraoperative Surgery Although the difference was not statistically significant (p = 0.8), males took somewhat longer to complete the operation (31.8 ± 12.7 minutes) than females (29.5 ± 10.5 minutes). Additionally, the groups' intraoperative blood loss was similar (20.8 ± 19.5 ml for males and 27.1 ± 35.9 ml for females; p = 0.68). There were no discernible gender-based variations in gallbladder morphology or pathological signs, such as distention, mucocele, contraction, edema, or pyocele. Features of the gallbladder wall, including inflammation, thickness, and thinning, were equally distributed in the two groups and did not reach statistical significance (p = 0.08). There was no discernible difference in the adherence to nearby structures between 34 males and 98 females (p = 0.91). Two female patients needed conversion to open cholecystectomy, whereas none of the male patients needed conversion (p = 0.25). Males and females had similar mean hospital stays (2.4 ± 1.2 days and 2.7 ± 1.6 days), although there was no statistically significant difference (p = 0.67). Table 2 Details of surgical outcomes in study participants. Surgical outcomes Group A Group B P-value N=40 Male patients N= 105 Female patients Operative time (mins) 31.8 ± 12.7 29.5 ± 10.5 0.8 Blood loss (ml) 20.8 ± 19.5 27.1 ± 35.9 0.68 Gall bladder Distention 21 97 0.28 Mucocele 3 16 Contraction 2 3 Edematous 1 1 Pyocele 1 2 Gall bladder wall Thin 17 82 0.08 Thick 11 38 Inflamed 7 18 Adhesion to adjacent structures 34 98 0.91 Converted to open 0 2 0.25 Hospital stay 2.4 ± 1.2 2.7 ± 1.6 0.67 World Journal of Advanced Research and Reviews, 2025, 27(02), 1372-1377 1375 3.3. Complications Following Surgery Nine male and sixty-five female patients experienced critical intraoperative episodes (p = 0.12). Two males and fourteen females experienced bile leakage (p = 0.82), and three males compared to thirty-three females experienced intraoperative hemorrhage (p = 0.12). Only four female patients experienced stone spilling; however, this was not statistically significant (p = 0.33). One male and two female patients had wound infections (p = 0.15), and one female patient had bilious extravasation (>14 days) (p = 0.59). The incidence of postoperative abdominal distension varied statistically significantly and only happened in one male patient (p = 0.04). There were no appreciable differences between the groups in any other difficulties. Table 3 Post-operative complications in study participants. Complication Group A Group B P-value N=40 Male patients N= 105 Female patients Critical episodes 9 65 0.12 Bile leakage 2 14 0.82 Bleeding 3 33 0.12 Stone spillage 0 4 0.33 Wound infection 1 2 0.15 Bilious Extravasation (>14 days) 0 1 0.59 Abdominal distension 1 0 0.04 4. Discussion Gallbladder stones are best treated by an approximation cholecystectomy (LC). Potential gender-based variations in clinical presentation, intraoperative parameters, and postoperative outcomes were examined in our study. According to research by Wang et al. (2021) and Acharya et al. (2022), there was no significant difference in the age or BMI of the patients, indicating that these factors are not gender-dependent predictors of LC results. Aydın et al. (2020) found that females had a considerably greater rate of prior abdominal surgery (p=0.01). This conclusion may be related to the higher rates of obstetric and gynecological procedures in women. The need for liver function evaluation before LC, particularly in male patients, is highlighted by the increased incidence of Hepatitis C in males, which is in line with epidemiological data from Pakistan and international research (Zaki et al., 2020). Gender differences in hospital stay, conversion rates, blood loss, and operating time were not statistically significant. These results are in line with global data from Lee et al. (2021) studies, which found no variation in conversion rates. Zhang et al. (2023) — demonstrating comparable operational measures for both sexes. Longer hospital stays and somewhat higher blood loss were observed in female patients, although these differences were not statistically significant. According to some research, this trend may be explained by technical variables, such as higher adhesion in females from prior procedures (Yücel et al., 2020). The comparable frequencies of adhesion and gallbladder wall alterations show that anatomical disease is consistent between genders. However, only female patients underwent conversion to open cholecystectomy, however this change was not statistically significant. Numerous investigations have documented this pattern (Singh et al., 2022), which could be connected to adhesions and chronic inflammation. According to recent meta-analyses, although females experienced greater rates of complications such as bile leakage, hemorrhage, and stone spilling, these differences were not statistically significant (Chen et al., 2022; Tan et al., 2021). It's interesting to note that males experienced stomach distension considerably more frequently (p=0.04). Similar patterns were observed, however infrequently, by Patel et al. (2020), who ascribed it to either residual pneumoperitoneum or potential peritoneal irritation. As noted in the works of Sharma & Verma (2021), a higher frequency of critical intraoperative events in females may once more reflect anatomical and pathological complexity brought on by previous surgeries. World Journal of Advanced Research and Reviews, 2025, 27(02), 1372-1377 1376 5. Conclusion Although gender has no discernible impact on the overall results of laparoscopic cholecystectomy, certain factors, such as a female's past surgical history and a male's Hepatitis C status, should be taken into account for preoperative evaluation and risk assessment. There is no evidence to support changing the surgical strategy depending only on a patient's gender. Compliance with ethical standards Disclosure of conflict of interest No conflict of interest to be disclosed. Statement of informed consent Informed consent was obtained from all individual participants included in the study. References [1] Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut and liver. 2012 Apr 17;6(2):172. [2] Keus F, de Jong J, Gooszen HG, Laarhoven CJ, Cochrane Hepato‐Biliary Group. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane database of systematic reviews. 1996 Sep 1;2010(1). [3] Aerts R, Penninckx F. The burden of gallstone disease in Europe. Alimentary pharmacology & therapeutics. 2003 Nov 2;18. [4] Chae KL, Park SY, Hong JI, Yim WJ, Lee SC, Chung CJ. The effect of gender and age on postoperative pain in laparoscopic cholecystectomy: a prospective observational study. Anesthesia and Pain Medicine. 2019 Jul 31;14(3):364-9. [5] Taha M, Aleesa BA, Algarni MA, Alomari SM, Alzubidy SH. Evaluating Patient Satisfaction and Quality of Life After Undergoing Laparoscopic Cholecystectomy in Al-Qunfudhah Governorate, Saudi Arabia. Cureus. 2024 Jun 12;16(6). [6] Rosen M, Brody F, Ponsky J. Predictive factors for conversion of laparoscopic cholecystectomy. The American journal of surgery. 2002 Sep 1;184(3):254-8. [7] Kama NA, Kologlu M, Doganay M, Reis E, Atli M, Dolapci M. A risk score for conversion from laparoscopic to open cholecystectomy. Am J Surg. 2001;181(6):520-5. [8] Licciardello A, Arena M, Nicosia A, Di Stefano B, Calì G, Arena G, Minutolo V. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy. European Review for Medical & Pharmacological Sciences. 2014 Dec 2;18. [9] Sakpal SV, Bindra SS, Chamberlain RS. Laparoscopic cholecystectomy conversion rates two decades later. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 2010 Oct;14(4):476. [10] Hugh TB. New strategies to prevent laparoscopic bile duct injury—surgeons can learn from pilots. Surgery. 2002 Nov 1;132(5):826-35. [11] Naseem AC, Fateh DK, Muhammad IB, Muhammad HL. Surgical incidence of cholelithiasis in Hyderabad and adjoining areas (Pakistan). Pak J Med Sci 2004; 20: 13-17. [12] Wang W, Sun X, Wei F. Laparoscopic surgery and robotic surgery for single-incision cholecystectomy: an updated systematic review. Updates in Surgery. 2021 Dec;73(6):2039-46. [13] GUPTA AA, DeSHPAnDe S. Correlation of Preoperative Scoring System with Intraoperative Scoring System for Predicting Difficult Laparoscopic Cholecystectomy: A Research Protoco. Journal of Clinical & Diagnostic Research. 2025 Jun 1;19(6). World Journal of Advanced Research and Reviews, 2025, 27(02), 1372-1377 1377 [14] Aktas A, Güner A, Güneş Ö, Karagül S, Karaköse O, Çolak E, Tardu A, Bayam ME, Demirbaş İE, Türkyılmaz Z, Simsek A. A detailed analysis of surgical site infections and risk factors: A multicentric cohort study in Türkiye. Journal of Experimental and Clinical Medicine. 2024 May 1;41(2):361-9. [15] Saleem U, Aslam N, Siddique R, Iqbal S, Manan M. Hepatitis C virus: Its prevalence, risk factors and genotype distribution in Pakistan. European Journal of Inflammation. 2022 Nov 30;20:1721727X221144391. [16] Son SY, Hur H, Hyung WJ, Park YK, Lee HJ, An JY, Kim W, Kim HI, Kim HH, Ryu SW, Kim MC. Laparoscopic vs open distal gastrectomy for locally advanced gastric cancer: 5-year outcomes of the KLASS-02 randomized clinical trial. JAMA surgery. 2022 Oct 1;157(10):879-86. [17] Monteleone AS, Salerno M, Mondini Trissino da Lodi C, Gonalba GC, Candrian C, Filardo G. The influence of sex is a neglected focus in rotator cuff repair: A systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2024 Oct;32(10):2699-710. [18] Karagöz H, Karaman A. Helicobacter pylori incidence of patients with gastritis in endoscopic biopsies. Journal of Surgery and Medicine. 2020 May 1;4(5):359-62. [19] Aggarwal K, Singh RP, Mishra A, Rani N, Pahuja V, Dugg P. Evaluation of factors responsible for conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: A prospective cohort study of 267 cases. J Int Med Sci Acad. 2024 Jan;37(1). [20] Ashraf S, Khan MS, Wattoo NM, Rashid AR, Zia SA. Gender-Based Differences in the Outcome of Laparoscopic Cholecystectomy in Patients with Gall Stones. Pakistan Armed Forces Medical Journal. 2024 Aug 31;74(4):961. [21] Hai HH, Aw P, Teng TZ, Shelat VG. Perioperative steroid administration reduces overall complications in patients undergoing liver resection: A meta-analysis. World Journal of Gastrointestinal Surgery. 2021 Sep 27;13(9):1079. [22] Abdihakim HM. Comparison of Pre-operative Ct Scan and Laparotomy Findings in Adult Patients With Blunt Abdominal Trauma at Kenyatta National Hospital: a Comparative Cross-sectional Study (Doctoral dissertation, University of Nairobi). [23] Thapar VB, Thapar PM, Goel R, Agarwalla R, Salvi PH, Nasta AM, Mahawar K. Evaluation of 30-day morbidity and mortality of laparoscopic cholecystectomy: a multicenter prospective observational Indian Association of Gastrointestinal Endoscopic Surgeons (IAGES) Study. Surgical endoscopy. 2023 Apr;37(4):2611-25. [24] Ten Broek RP, Issa Y, van Santbrink EJ, Bouvy ND, Kruitwagen RF, Jeekel J, Bakkum EA, Rovers MM, van Goor H. Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. Bmj. 2013 Oct 3;347. [25] Bashir MF, Riaz MA, Saeed M, Riaz S. PREVALENCE OF DIABETES MELLITUS AND ITS ASSOCIATION WITH HEPATITIS C VIRUS-INFECTED PAKISTANI FEMALES. THE JOURNAL OF MICROBIOLOGY AND MOLECULAR GENETICS. 2023 Apr 30;4(1):47-58. [26] Banik, S., Khan, M.S.I., Jami, H., Sivasubramanian, M., Dhakal, M. and Wilson, E., 2023. Social determinants of sexual health among sexual and gender diverse people in South Asia: Lessons learned from India, Bangladesh, Nepal, and Pakistan. In Transforming Unequal Gender Relations in India and Beyond: An Intersectional Perspective on Challenges and Opportunities (pp. 327-352). Singapore: Springer Nature Singapore.