Taizo Hibi, MD, PhD1, Yukio Iwashita2, Tetsuji Ohyama2, Goro Honda3, Masahiro Yoshida4, Tadahiro Takada5, Ho-Seong Han6, Tsann-Long Hwang7, Go Wakabayashi8, Masakazu Yamamoto9. 1Keio University School of Medicine, 2Oita University Faculty of Medicine, 3Tokyo Metropolitan Komagome Hospital, 4International University of Health and Welfare, 5Teikyo University School of Medicine, 6Seoul National University Bundang Hospital, 7Lin-Kou Chang Gung Memorial Hospital, 8Ageo Central General Hospital, 9Tokyo Women’s Medical University
Introduction: Serious biliary and vascular complications continue to develop in laparoscopic cholecystectomy (LC). Previous attempts to identify predictors of “difficult LC” have failed to provide high-level evidence because surgeon- and institution-dependent variables prevented general acceptance. In 2014, we launched a multinational project to establish a novel evaluation system of surgical difficulty based on intraoperative findings and the results of the preliminary survey have been reported recently. We will describe the current work in progress.
Methods: A large-scale, multinational survey including >500 participants among Japan, Korea, and Taiwan was conducted to elucidate the difference in LC practice and to compare expert surgeons’ perceptions on safety measures and intraoperative judgments on when to abandon conventional LC and convert to open cholecystectomy, partial cholecystectomy, etc. undertaken during LC. The questionnaire was also designed to address 25 intraoperative findings that potentially contribute to surgical difficulty and participants were asked to grade each factor depending on its impact on surgical difficulty. This component of the survey was conducted as the first round Delphi process. Thereafter, all participants were invited to the second round Delphi for consensus building.
Results: There was a statistically significant difference (p < 0.05) among nations in the maximum duration of surgery allowed, the use of intraoperative cholangiogram, “critical view of safety” technique, identification of Rouviere’s sulcus, and application of the SS-inner theory during LC and the difference prevailed even when stratified by LC experience. For the maximum estimated blood loss allowed, the difference disappeared among those with LC experience ≥500 cases. Korean surgeons were more likely to continue with conventional LC in each experience category regardless of the circumstances (extensive operative time and/or blood loss, damage to adjacent organs or biliary tract injury, adhesion to surrounding organs, and fibrosis and scarring in Calot’s triangle or gallbladder bed) compared with those of Japan and Taiwan (p < 0.05). On the contrary, consensus on surgical difficulty based on 25 intraoperative findings (2 categories: 1. Factors related to inflammation of the gallbladder, and 2. Intra-abdominal factors unrelated to inflammation of the gallbladder) was successfully built after 2 rounds of Delphi process.
Conclusions: LC practice and expert surgeons’ perceptions on safety measures and intraoperative judgments during LC significantly differ among nations. A gold standard based on intraoperative, objective findings should be established to universally evaluate surgical difficulty, which would serve as the foundation of future LC-related studies.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79119
Program Number: S006
Presentation Session: Biliary
Presentation Type: Podium