What are the appropriate indicators of surgical difficulty during laparoscopic cholecystectomy? Results from a Japan‐Korea‐Taiwan multinational survey

Abstract

Background Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC. Methods A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT. Results The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons. Conclusions Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.

An opportunity in difficulty: Japan-Korea-Taiwan expert Delphi consensus on surgical difficulty during laparoscopic cholecystectomy

“…In contrast, the methodology in the present study aimed to systematically eliminate subjectivity and individual surgeon bias. We achieved this by using well-defined classification scheme for 25 specific intraoperative findings that have previously been demonstrated to potentially contribute to surgical difficulty by the nominal group technique [15]. Our study was intended to establish a gold standard that could be universally adopted to grade surgical difficulty and the approach we adopted was essentially novel.…”

“…A total of 554 surgeons were invited to vote for the first and second-round Delphi process in a web-based questionnaire. This included 61 expert LC surgeons of Japan, Korea, and Taiwan who had participated in the preliminary survey [15]. The language used was English, and the questions were designed to grade 25 potential factors contributing to surgical difficulty.…”

“…The language used was English, and the questions were designed to grade 25 potential factors contributing to surgical difficulty. These 25 factors were considered to be objective findings and appropriate indicators of surgical difficulty per the nominal group technique [15]. Each of these 25 factors could be identified at the time of operation and classified according to a seven-stage scale ranging from 0 to 6.…”

“…However, these factors are strongly affected by the skill of each surgeon and center's policy. A previous multinational survey by our group comprising expert LC surgeons in Japan, Korea, and Taiwan revealed that surgeons' perceptions and routinely taken safety measures during LC are workplace-dependent [15,16]. Moreover, several studies suggesting intraoperative findings as useful indices to grade surgical difficulty [17][18][19] have failed to evolve to a multicenter trial and thus the evidence is not the highest level attainable.…”

“…for evaluation, resulting in considerable bias among operators. To eradicate variability among institutions and surgeons and provide objectivity, we generated a list of 25 key intraoperative findings that potentially contribute to surgical difficulty during LC using the nominal group technique [15]. By weighting each of these items according to its impact, we propose to establish a gold standard to universally grade surgical difficulty during LC.…”