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Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

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SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES, 33 (1). pp. 110-121. ISSN 0930-2794 https://doi.org/10.1007/s00464-018-6281-2
SGUL Authors: Sinha, Sidhartha

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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.

Item Type: Article
Additional Information: © The Author(s) 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Correction available at https://doi.org/10.1007/s00464-018-6377-8
Keywords: Surgery, Laparoscopic, Cholecystectomy, Operative difficulty, Difficulty grading, 1103 Clinical Sciences, Surgery
SGUL Research Institute / Research Centre: Academic Structure > Molecular and Clinical Sciences Research Institute (MCS)
Academic Structure > Molecular and Clinical Sciences Research Institute (MCS) > Vascular & Cardiac Surgery (INCCVC)
Journal or Publication Title: SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
ISSN: 0930-2794
Dates:
DateEvent
January 2019Published
28 June 2018Published Online
18 June 2018Accepted
Publisher License: Creative Commons: Attribution 4.0
Web of Science ID: WOS:000456089200014
URI: http://openaccess.sgul.ac.uk/id/eprint/110663
Publisher's version: https://doi.org/10.1007/s00464-018-6281-2

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