Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

• Published in: Surgical endoscopy Vol. 33; no. 1; pp. 110 - 121
• Main Authors: Griffiths, Ewen A., Hodson, James, Vohra, Ravi S., Marriott, Paul, Katbeh, Tarek, Zino, Samer, Nassar, Ahmad H. M.
• Format: Journal Article
• Language: English
• Published: New York Springer US 01.01.2019; Springer Nature B.V
• Subjects: Abdominal Surgery; Adult; Aged; Bile ducts; Cholecystectomy; Cholecystectomy, Laparoscopic - adverse effects; Cholecystectomy, Laparoscopic - standards; Cholecystectomy, Laparoscopic - statistics & numerical data; Conversion to Open Surgery - statistics & numerical data; Datasets; Endoscopy; Female; Gallbladder; Gastroenterology; Gynecology; Hepatology; Hospitals; Humans; Laparoscopy; Length of Stay - statistics & numerical data; Male; Medicine; Medicine & Public Health; Middle Aged; Mortality; Multivariate Analysis; Patients; Postoperative Complications; Proctology; Prospective Studies; R&D; Research & development; ROC Curve; Small intestine; Surgeons; Surgery; Surgical outcomes; Cholecystectomy; Operative difficulty; Difficulty grading; Laparoscopic; Surgery
• ISSN: 0930-2794; 1432-2218; 1866-6817; 1432-2218
• DOI: 10.1007/s00464-018-6281-2

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.