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Surg Endosc. 2019 Jan;33(1):110-121. doi: 10.1007/s00464-018-6281-2. Epub 2018 Jun 28.

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.

Author information

1
Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
2
Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
3
Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
4
Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK.
5
West Midlands Research Collaborative, Academic Department of Surgery, Birmingham University, Birmingham, UK.
6
Department of Surgery, Warwick Hospital, Lakin Rd, Warwick, UK.
7
Department of Surgery, University Hospital Monklands, Lanarkshire, Scotland, UK.
8
Department of Surgery, University Hospital Monklands, Lanarkshire, Scotland, UK. ahmad.nassar@glasgow.ac.uk.

Abstract

BACKGROUND:

A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets.

METHODS:

Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall's tau for dichotomous variables, or Jonckheere-Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis.

RESULTS:

A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001).

CONCLUSION:

We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty.

KEYWORDS:

Cholecystectomy; Difficulty grading; Laparoscopic; Operative difficulty; Surgery

PMID:
29956029
PMCID:
PMC6336748
DOI:
10.1007/s00464-018-6281-2
[Indexed for MEDLINE]
Free PMC Article

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