Abstract
BACKGROUND: Accurately identifying difficult laparoscopic cholecystectomy (DLC) preoperatively remains a clinical challenge. Previous studies utilizing clinical variables or morphological imaging markers have demonstrated suboptimal predictive performance. This study aims to develop an optimal radiomics-clinical model by integrating preoperative CT-based radiomics features with clinical characteristics. METHODS: A retrospective analysis was conducted on 2,055 patients who underwent laparoscopic cholecystectomy (LC) for cholecystitis at our center. Preoperative CT images were processed with super-resolution reconstruction to improve consistency, and high-throughput radiomic features were extracted from the gallbladder wall region. A combination of radiomic and clinical features was selected using the Boruta-LASSO algorithm. Predictive models were constructed using six machine learning algorithms and validated, with model performance evaluated based on the AUC, accuracy, Brier score, and DCA to identify the optimal model. Model interpretability was further enhanced using the SHAP method. RESULTS: The Boruta-LASSO algorithm identified 10 key radiomic and clinical features for model construction, including the Rad-Score, gallbladder wall thickness, fibrinogen, C-reactive protein, and low-density lipoprotein cholesterol. Among the six machine learning models developed, the radiomics-clinical model based on the random forest algorithm demonstrated the best predictive performance, with an AUC of 0.938 in the training cohort and 0.874 in the validation cohort. The Brier score, calibration curve, and DCA confirmed the superior predictive capability of this model, significantly outperforming previously published models. The SHAP analysis further visualized the importance of features, enhancing model interpretability. CONCLUSION: This study developed the first radiomics-clinical random forest model for the preoperative prediction of DLC by machine learning algorithms. This predictive model supports safer and individualized surgical planning and treatment strategies.