ArticleSurgical endoscopy2019
Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.
Article in Surgical endoscopy, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. An erratum has been issued. It is linked to trial NCT07695922 (A Single-Centre, Non-Randomised Interventional Study for the Implementation of the Enhanced Recovery After Surgery), which is not on this map. Cited by 73 papers, 3 of them syntheses that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
A Single-Centre, Non-Randomised Interventional Study for the Implementation of the Enhanced Recovery After Surgery (RICA) Guidelines in Patients With Tokyo Guidelines 2018 Grade II Acute Cholecystitis Undergoing Early Laparoscopic Cholecystectomy
Who cites it
73 citing papers in PubMed, 3 syntheses or guidelines pooled it.
- Lost gallstones during laparoscopic cholecystectomy as a common but underestimated complication-case report and review of the literature.Frontiers in surgery · 2024Pooled it
- It's time for a minimum synoptic operation template in patients undergoing laparoscopic cholecystectomy: a systematic review.World journal of emergency surgery : WJES · 2022Pooled it
- Perioperative outcomes after laparoscopic cholecystectomy in elderly patients: a systematic review and meta-analysis.Surgical endoscopy · 2020Pooled it
- Trial
- Low-pressure pneumoperitoneum with deep neuromuscular blockade versus standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy for gallstone disease: a non-inferiority randomized control trial.Surgical endoscopy · 2024Trial
- Comparison of a new gasless method and the conventional COUpdates in surgery · 2021Trial
- 3D laparoscopy does not reduce operative duration or errors in day-case laparoscopic cholecystectomy: a randomised controlled trial.Surgical endoscopy · 2020Trial
- Preoperative prediction of acute severe cholecystitis using an attentive interpretable tabular network (TabNet)-based radiomics model and a stacking ensemble: a two-center study.Annals of medicine · 2026Article
- Artificial intelligence assessment of Parkland's grading scale in laparoscopic cholecystectomy: a step toward real-world outcome prediction.Updates in surgery · 2026Article
- Artificial Intelligence for Automated Recognition of Hepatocystic Anatomy During Laparoscopic Cholecystectomy: Current Evidence, Clinical Readiness, and Future Directions.Medicina (Kaunas, Lithuania) · 2026Review
- Red, amber, green: how the traffic light system predicts surgical challenges in laparoscopic cholecystectomy for gallstone disease.Updates in surgery · 2026Article
- Article
- Revisiting the seven-day rule: an international retrospective analysis of laparoscopic cholecystectomy for acute cholecystitis.Surgical endoscopy · 2026Article
- Article
- Learning from single timestamps: complexity estimation in laparoscopic cholecystectomy.International journal of computer assisted radiology and surgery · 2026Article
- Towards measuring the challenge: a narrative review on existing concepts and parallels for surgical struggle.Surgical endoscopy · 2026Review
- Construction and validation of a diagnostic model for acute suppurative cholecystitis in older patients: LASSO-Logistic regression analysis using readily available clinical indicators.BMC geriatrics · 2026Article
- Deep learning enables accurate diagnosis of acute cholecystitis and prediction of suppuration using noncontrast CT.iScience · 2025Article
- Bile Duct Injury and Litigation in Laparoscopic Cholecystectomy: A Global Review of Current and Future Preventative Initiatives.Annals of surgery open : perspectives of surgical history, education, and clinical approaches · 2025Review
- Robotic emergency general surgery, future or fallacy?: case-matched comparison of operative and clinical outcomes during the adoption phase in a tertiary centre.Journal of robotic surgery · 2025Article
13 more citing papers are in PubMed but not listed here.
Corrections and comments
- Erratum issued
- Erratum issued
Authors and funding
9 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundA 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.
methodsPatient 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.
resultsA 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).
conclusionWe 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.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.