Two operative grading systems to define the difficulty of cholecystectomy
Ewen Griffiths, Univerisity Hospitals Birmingham NHS Foundation Trust
23 June 2015
I read this paper with interest, but sadly the authors of this paper erroneously state that no previous operative difficulty grading systems has ever been published with regards to laparoscopic cholecystectomy.
They have missed two previous publications on this very topic.
Cuschieri et al published this 'scale of difficulty' for laparoscopic cholecystectomy in this textbook in 1992 and this was slightly modified in a further publication in in The Lancet in 1998.
The first Scale is as follows:
Grade 1 (easy / uncomplicated cholecystectomy)
Grade 2 (medium difficulty, for example mild cholecystitis, cystic duct orartery obscured by adhesions or fatty tissue; mucoele may be present)
Grade 3 (difficult cholecystectomy due to either gangrenous cholecystitis;shrunken fibrotic gallbladder; severe cholecystitis; subhepatic abscess formation; Hartman pouch adherent to the CHD; cases in which the cystic duct or artery are difficult or impossible to dissect; or liver cirrhosis with portal hypertension)
Grade 4 (conversion to open surgery is required)
Nassar et al in 1995 published his grading system; which graded operative findings from the gallbladder, cystic pedicle and associated adhesions.
Grade 1 - Gallbladder - floppy, non-adherent; Cystic pedicle - thin and clear; Adhesions - Simple up to the neck / Hartmann's pouch
Grade 2 - Gallbladder - Mucocele, Packed with stones; Cystic pedicle - Fat laden; Adhesions - Simple up to the body
Grade 3 - Gallbladder - Deep fossa, Acute cholecystitis, Contracted, Fibrosis,;Hartmans adherent to CBD, Impaction; Cystic pedicle - Abnormal anatomy or cystic duct - short, dilated or obscured; Adhesions -Dense up to fundus; Involving hepatic flexure or duodenum
Grade 4 - Gallbladder - Completely obscured, Empyema, Gangrene, Mass; Cystic pedicle - Impossible to clarify; Adhesions - Dense, fibrosis, wrapping the gallbladder, Duodenum or hepatic flexure difficult to separate
Cuschieri A, Berci G. Laparoscopic Biliary Surgery. Edinburgh: Blackwell Scientific Publication, 1992
Cuschieri;A. Randomised study of influence of two-dimensional versus three-dimensional imaging on performance of laparoscopic cholecystectomy. Lancet;1998 Jan 24;351(9098):248-51.
Nassar, AHM , Ashkar KA , Mohamed AY , and Hafiz AA .Is laparoscopic cholecystectomy possible without video technology? Min Invas Ther;1995. 4 (2):63
Competing interests
Ewen A Griffiths is involved with the West Midlands Research Collaboration (http://wmresearch.org.uk/) and is leading the CholeS study which is a large prospective study assessing outcomes of cholecystectomy in the UK (www.choles-study.org). This study uses the Nassar grading system to stratefy operative difficulty of cholecystectomy.
A response to "Two operative grading systems to define the difficulty of cholecystectomy" by Ewen Griffiths
michael sugrue, letterkenny hospital
23 June 2015
We would like to thank Ewen Griffiths for his interest in and comments relating to our article - Grading operative findings at laparoscopic cholecystectomy- a new scoring system [1].
The literature review process for this paper was undertaken primarily by MS and secondarily by SS with the addition of two library searches conducted by professional librarians. It was further supplemented by a very extensive manual search, akin to the old Index Medicus searches of former years.
The publications by Hanna et al in Lancet (1998) [2] and Nassar et al [3] in Minimally Invasive Therapy (1995) were not detected by the search process. The former did not have any wording to suggest that there was any grading/scoring of the gallbladder in the title and Key Words were not used. The second paper has (to our knowledge) not be cited in Pubmed and makes no reference to grading in its title.
It was nice to read these two articles relating primarily to laparoscopic imaging systems used during laparoscopic cholecystectomy. A grade of difficulty was proposed in both papers and interestingly Hanna, in their 1998 paper, makes no reference to Nassar's 1995 publication. It is a very subjective grade system and no score is used.
In our conclusion in our paper we state "This paper reports one of the first operative classifications of findings at laparoscopic cholecystectomy". We stick to that assertion and thank Dr Griffiths for his interest and hope we can move forward with a more universal bench marking of one of the most commonly performed operations.
[1] Sugrue M, Sahebally S, Ansaloni L, Zielinski M. Grading operative findings at laparoscopic cholecystectomy- a new scoring system. World Journal of Emergency Surgery 2015, 10:14 doi:10.1186/s13017-015-0005-x
[2] Hanna GB, Shimi SM, Cuschieri A. Randomised study of influence of two-dimensional versus three-dimensional imaging on performance of laparoscopic cholecystectomy. Lancet. 1998 Jan 24;351(9098):248-51.
[3] Nassar, AHM , Ashkar KA , Mohamed AY , and Hafiz AA . Is laparoscopic cholecystectomy possible without video technology? Min Invas Ther 1995. 4 (2):63–65.
Michael Sugrue
Shaheel Sahebelly
Luca Ansaloni
Martin D Zielinski
Competing interests
I am the corresponding author of this article, otherwise I declare that I have no competing interests
A difficulty grading classification for laparoscopic cholecystectomy, Nassar Scale 1995
Ahmad Nassar, NHS Lanarkshire, Scotland
6 August 2015
I read with interest the article and the two comments. It is of course true that a number of scales/scores have been described. However there was always a need for a simplified scale based on operative findings that can be adopted widely and the use of which can be vaildated through large studies such as the one conducted by Mr Griffiths across the UK.
I have used the difficulty grading system/classification published 1995 in Minimally Invasive Therapy since 1992. Within two years I modified the scale to allow for more specific pathology encountered during cholecystectomies.
I never included the need to convert to open cholecystectomy in the classification. I do not believe that open conversion is a reflection, or necessarily the result of the difficulty encountered. Some conversions happen in failry easy cases for many reasons e.g stone spillage or a bowel injury.
A difficulty grading classification which helps reporting operative findings is useful for descriptive purposes, for research and audit and for easier and standardised comparison between studies.
It is also a fairer way of assessing trainees and completing their training curriculum.
The modified classification , and an example of its applications in a large clinical series can be seen below
World Journal of Emergency Surgery
Two operative grading systems to define the difficulty of cholecystectomy
23 June 2015
I read this paper with interest, but sadly the authors of this paper erroneously state that no previous operative difficulty grading systems has ever been published with regards to laparoscopic cholecystectomy.
They have missed two previous publications on this very topic.
Cuschieri et al published this 'scale of difficulty' for laparoscopic cholecystectomy in this textbook in 1992 and this was slightly modified in a further publication in in The Lancet in 1998.
The first Scale is as follows:
Grade 1 (easy / uncomplicated cholecystectomy)
Grade 2 (medium difficulty, for example mild cholecystitis, cystic duct orartery obscured by adhesions or fatty tissue; mucoele may be present)
Grade 3 (difficult cholecystectomy due to either gangrenous cholecystitis;shrunken fibrotic gallbladder; severe cholecystitis; subhepatic abscess formation; Hartman pouch adherent to the CHD; cases in which the cystic duct or artery are difficult or impossible to dissect; or liver cirrhosis with portal hypertension)
Grade 4 (conversion to open surgery is required)
Nassar et al in 1995 published his grading system; which graded operative findings from the gallbladder, cystic pedicle and associated adhesions.
Grade 1 - Gallbladder - floppy, non-adherent; Cystic pedicle - thin and clear; Adhesions - Simple up to the neck / Hartmann's pouch
Grade 2 - Gallbladder - Mucocele, Packed with stones; Cystic pedicle - Fat laden; Adhesions - Simple up to the body
Grade 3 - Gallbladder - Deep fossa, Acute cholecystitis, Contracted, Fibrosis,;Hartmans adherent to CBD, Impaction; Cystic pedicle - Abnormal anatomy or cystic duct - short, dilated or obscured; Adhesions -Dense up to fundus; Involving hepatic flexure or duodenum
Grade 4 - Gallbladder - Completely obscured, Empyema, Gangrene, Mass; Cystic pedicle - Impossible to clarify; Adhesions - Dense, fibrosis, wrapping the gallbladder, Duodenum or hepatic flexure difficult to separate
There are illustrative examples of these degrees of difficulties with laparoscopic videos on the following website http://www.schoolofsurgery.org/hpb-transplant/biliary/a-difficult-gallbladder/ which the readers may find helpful.
References:Cuschieri A, Berci G. Laparoscopic Biliary Surgery. Edinburgh: Blackwell Scientific Publication, 1992
Cuschieri;A. Randomised study of influence of two-dimensional versus three-dimensional imaging on performance of laparoscopic cholecystectomy. Lancet;1998 Jan 24;351(9098):248-51.
Nassar, AHM , Ashkar KA , Mohamed AY , and Hafiz AA .Is laparoscopic cholecystectomy possible without video technology? Min Invas Ther;1995. 4 (2):63
Competing interests
Ewen A Griffiths is involved with the West Midlands Research Collaboration (http://wmresearch.org.uk/) and is leading the CholeS study which is a large prospective study assessing outcomes of cholecystectomy in the UK (www.choles-study.org). This study uses the Nassar grading system to stratefy operative difficulty of cholecystectomy.A response to "Two operative grading systems to define the difficulty of cholecystectomy" by Ewen Griffiths
23 June 2015
We would like to thank Ewen Griffiths for his interest in and comments relating to our article - Grading operative findings at laparoscopic cholecystectomy- a new scoring system [1].
The literature review process for this paper was undertaken primarily by MS and secondarily by SS with the addition of two library searches conducted by professional librarians. It was further supplemented by a very extensive manual search, akin to the old Index Medicus searches of former years.
The publications by Hanna et al in Lancet (1998) [2] and Nassar et al [3] in Minimally Invasive Therapy (1995) were not detected by the search process. The former did not have any wording to suggest that there was any grading/scoring of the gallbladder in the title and Key Words were not used. The second paper has (to our knowledge) not be cited in Pubmed and makes no reference to grading in its title.
It was nice to read these two articles relating primarily to laparoscopic imaging systems used during laparoscopic cholecystectomy. A grade of difficulty was proposed in both papers and interestingly Hanna, in their 1998 paper, makes no reference to Nassar's 1995 publication. It is a very subjective grade system and no score is used.
In our conclusion in our paper we state "This paper reports one of the first operative classifications of findings at laparoscopic cholecystectomy". We stick to that assertion and thank Dr Griffiths for his interest and hope we can move forward with a more universal bench marking of one of the most commonly performed operations.
[1] Sugrue M, Sahebally S, Ansaloni L, Zielinski M. Grading operative findings at laparoscopic cholecystectomy- a new scoring system. World Journal of Emergency Surgery 2015, 10:14 doi:10.1186/s13017-015-0005-x
[2] Hanna GB, Shimi SM, Cuschieri A. Randomised study of influence of two-dimensional versus three-dimensional imaging on performance of laparoscopic cholecystectomy. Lancet. 1998 Jan 24;351(9098):248-51.
[3] Nassar, AHM , Ashkar KA , Mohamed AY , and Hafiz AA . Is laparoscopic cholecystectomy possible without video technology? Min Invas Ther 1995. 4 (2):63–65.
Michael Sugrue
Shaheel Sahebelly
Luca Ansaloni
Martin D Zielinski
Competing interests
I am the corresponding author of this article, otherwise I declare that I have no competing interestsA difficulty grading classification for laparoscopic cholecystectomy, Nassar Scale 1995
6 August 2015
I read with interest the article and the two comments. It is of course true that a number of scales/scores have been described. However there was always a need for a simplified scale based on operative findings that can be adopted widely and the use of which can be vaildated through large studies such as the one conducted by Mr Griffiths across the UK.
I have used the difficulty grading system/classification published 1995 in Minimally Invasive Therapy since 1992. Within two years I modified the scale to allow for more specific pathology encountered during cholecystectomies.
I never included the need to convert to open cholecystectomy in the classification. I do not believe that open conversion is a reflection, or necessarily the result of the difficulty encountered. Some conversions happen in failry easy cases for many reasons e.g stone spillage or a bowel injury.
A difficulty grading classification which helps reporting operative findings is useful for descriptive purposes, for research and audit and for easier and standardised comparison between studies.
It is also a fairer way of assessing trainees and completing their training curriculum.
The modified classification , and an example of its applications in a large clinical series can be seen below
http://www.epostersonline.com/asgbi2014/?q=node/3031
Competing interests
No competing interests