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

Abstract

Background We previously identified 25 intraoperative findings during laparoscopic cholecystectomy (LC) as potential indicators of surgical difficulty per nominal group technique. This study aimed to build a consensus among expert LC surgeons on the impact of each item on surgical difficulty. Methods Surgeons from Japan, Korea, and Taiwan (n = 554) participated in a Delphi process and graded the 25 items on a seven-stage scale (range, 0-6). Consensus was defined as (1) the interquartile range (IQR) of overall responses ≤2 and (2) ≥66% of the responses concentrated within a median AE 1 after stratification by workplace and LC experience level. Results Response rates for the first and the second-round Delphi were 92.6% and 90.3%, respectively. Final consensus was reached for all the 25 items. 'Diffuse scarring in the Calot's triangle area' in the 'Factors related to inflammation of the gallbladder' category had the strongest impact on surgical difficulty (median, 5; IQR, 1). Surgeons agreed that the surgical difficulty increases as more fibrotic change and scarring develop. The median point for each item was set as the difficulty score. Conclusions A Delphi consensus was reached among expert LC surgeons on the impact of intraoperative findings on surgical difficulty.

Optimal timing of cholecystectomy after percutaneous gallbladder drainage for severe cholecystitis

“…AC progresses from edematous cholecystitis through necrotizing cholecystitis to sub-acute cholecystitis in about 10 days, and edematous phase, which is a phase before proceeding tight adhesion, lasts for 72 h after symptom onset [22]. Necrotizing cholecystitis is also reported to be one of the risk factor for difficult LC [23, 24]. Thus, the Tokyo Guidelines recommend early LC.…”

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul‐de‐sac or the birth pangs of a new technical framework?

“…For the past few years, we have been striving to define surgical difficulty during LC based on objective, intraoperative findings [17,18,45]. Although a universal grading system has yet to be defined, we have set a difficulty score per expert consensus [45].…”

“…Disappointingly, the number of BDI cases does not seem to have gone down over the years, despite the introduction of other safety measures such as intraoperative cholangiography [12], use of landmarks other than CVS [13,14], and efforts to facilitate surgical education [15,16]. BDI may also occur in difficult situations, particularly in acute cholecystitis (AC) [17,18]. A recent study demonstrated an increased risk of BDI according to the severity grade of AC per Tokyo Guidelines 13 [19,20].…”

Predicting operative difficulty of laparoscopic cholecystectomy in patients with acute biliary presentations

“…Intra‐operative findings were systematically graded on a scale of 1–4 by the surgeon during the operation. The grading system represents a concise but simplified modification of intra‐operative factors known to be associated with the degree of difficulty of LC . Grades 1 and 2 were considered ‘straightforward’ operations, and grades 3 and 4 were considered ‘complicated’ operations as illustrated in Figure .…”

“…A complex or prolonged operation may result from unexpected intra‐operative findings that cannot be dealt with by on‐call surgeons or trainees who do not have the requisite skills or experience. Severe inflammation around the gallbladder (GB) can make safe dissection difficult, and may increase the risk of both minor and major complications . When an early LC policy is adopted for patients with acute biliary presentations it would be helpful to predict the degree of operative difficulty.…”