The Delphi Project: Defining Cholecystectomy as “Difficult” by Spanish Experts

Abstract

Purpose: To agree on a consensual definition of a cholecystectomy as “difficult”, it is mandatory to establish the criteria that should be included in this definition. Our goal is to achieve a national expert consensus on the characteristics for defining a cholecystectomy as "difficult". Methods: We carried out a Delphi study on the items that should be considered to define this surgery as difficult. A history of biliary pathology, preoperative clinical, analytical, and radiological data and intraoperative findings were selected based on the literature. Each of the items could only be answered using a 5-point Likert scale. Unanimity" was determined when 100% of the participants agreed on the same category; "Consensus" when there was ≥80% agreement; and "Majority" when the agreement involved ≥70%. Results: After the two rounds performed, the criteria that reached consensus were intraoperative finding of bile duct injury (96.77%); intraoperative finding of non-obvious anatomy (93.55%), Mirizzi's syndrome on imaging test (93. 55%), intraoperative finding of severe inflammation in Calot's triangle (90.32%), conversion to laparotomy (87.10%), time since the last acute cholecystitis (83.87%), scleroatrophic gallbladder on imaging test (80.65%), and intraoperative finding of abscess (80.65%). Conclusion: Predicting the difficulty of a cholecystectomy offers advantages in terms of the procedure's safety and improved results. But it is essential, as a preliminary step, to establish the items that define this procedure as difficult. The unification of criteria can lead to scores to predict the difficulty preoperatively and/or intraoperatively, which in turn can allow the comparison of groups of similar difficulty.