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SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy



Although it has been 25 years since the introduction of laparoscopy to cholecystectomy, outcomes remain largely unchanged, with rates of bile duct injury higher in the modern age than in the era of open surgery. The SAGES Safe Cholecystectomy Task Force (SCTF) initiative seeks to encourage a culture of safety in laparoscopic cholecystectomy (LC) and reduce biliary injury. An expert consensus study was conducted to identify interventions thought to be most effective in pursuit of this goal.


An initial list of items for safer practice in LC was identified by the SCTF through a nominal group technique (NGT) process. These were put forward to 407 SAGES committee members in two-stage electronically distributed Delphi surveys. Consensus was achieved if at least 80 % of respondents ranked an item as 4 or 5 on a Likert scale of importance (1–5). Additionally, respondents ranked five top areas of importance for the following domains: training, assessment, and research.


Thirty-nine initial items were identified through NGT. Response rates for each Delphi round were 40.2 and 34 %, respectively. Final consensus was achieved on 15 items, the majority of which related to non-technical factors in LC. Key domains for training, assessment, and research were identified. Critical view of safety was deemed most important for overall safety, as well as training and assessment of LC. Intraoperative cholangiography was identified as an additional priority area for future research.


Consensus items to progress surgical practice, training, assessment, and research have been identified, to promote safe practice and improve patient outcomes in LC.

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  1. 1.

    Litynski GS (1999) Profiles in laparoscopy: Mouret, Dubois, and Perissat—the laparoscopic breakthrough in Europe (1987–1988). JSLS 3:163–167

  2. 2.

    Dubois F, Icard P, Berthelot G, Levard H (1990) Coelioscopic cholecystectomy. Preliminary report of 36 cases. Ann Surg 211:60–62

  3. 3.

    Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ (2006) Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 18(4):CD006231

  4. 4.

    Unger SW, Rosenbaum G, Unger HM, Edelman DS (1993) A comparison of laparoscopic and open treatment of acute cholecystitis. Surg Endosc 7:408–411

  5. 5.

    Shaffer EA (2006) Gallstone disease: epidemiology of gallbladder stone disease. Best Pract Res Clin Gastroenterol 20:981–996

  6. 6.

    McMahon AJ, Russell IT, Baxter JN, Ross S, Anderson JR, Morran CG, Sunderland G, Galloway D, Ramsay G, O’Dwyer PJ (1994) Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial. Lancet 343:135–138

  7. 7.

    The Southern Surgeons Club (1991) A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 324:1073–1078

  8. 8.

    Raute M, Schaupp W (1988) Iatrogenic damage of the bile ducts caused by cholecystectomy. Treatment and results. Langenbecks Arch Chir 373:345–354

  9. 9.

    Morgenstern L, Wong L, Berci G (1992) Twelve hundred open cholecystectomies before the laparoscopic era. A standard for comparison. Arch Surg 127:400–403

  10. 10.

    Harboe KM, Bardram L (2011) The quality of cholecystectomy in Denmark: outcome and risk factors for 20,307 patients from the national database. Surg Endosc 25:1630–1641

  11. 11.

    Waage A, Nilsson M (2006) Iatrogenic bile duct injury: a population-based study of 152 776 cholecystectomies in the Swedish Inpatient Registry. Arch Surg 141:1207–1213

  12. 12.

    Flum DR, Dellinger EP, Cheadle A, Chan L, Koepsell T (2003) Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA 289:1639–1644

  13. 13.

    Navez B, Ungureanu F, Michiels M, Claeys D, Muysoms F, Hubert C, Vanderveken M, Detry O, Detroz B, Closset J, Devos B, Kint M, Navez J, Zech F, Gigot JF, Belgian Group for Endoscopic S, the H, Pancreatic Section of the Royal Belgian Society of S (2012) Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium. Surg Endosc 26:2436–2445

  14. 14.

    Stewart L, Way LW (1995) Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg 130:1123–1128

  15. 15.

    Bouras G, Burns EM, Howell AM, Bagnall NM, Lee H, Athanasiou T, Darzi A (2014) Systematic review of the impact of surgical harm on quality of life after general and gastrointestinal surgery. Ann Surg 260(6):975–983

  16. 16.

    Tornqvist B, Zheng Z, Ye W, Waage A, Nilsson M (2009) Long-term effects of iatrogenic bile duct injury during cholecystectomy. Clin. Gastroenterol Hepatol 7:1013–1018

  17. 17.

    Pucher PH, Aggarwal R, Qurashi M, Darzi A (2014) Meta-analysis of the effect of postoperative in-hospital morbidity on long-term patient survival. Br J Surg 101(12):1499–1508

  18. 18.

    Kern KA (1997) Malpractice litigation involving laparoscopic cholecystectomy. Cost, cause, and consequences. Arch Surg 132:392–397

  19. 19.

    McLean TR (2006) Risk management observations from litigation involving laparoscopic cholecystectomy. Arch Surg 141:643–648

  20. 20.

    Alkhaffaf B, Decadt B (2010) 15 years of litigation following laparoscopic cholecystectomy in England. Ann Surg 251:682–685

  21. 21.

    Berci G, Hunter J, Morgenstern L, Arregui M, Brunt M, Carroll B, Edye M, Fermelia D, Ferzli G, Greene F, Petelin J, Phillips E, Ponsky J, Sax H, Schwaitzberg S, Soper N, Swanstrom L, Traverso W (2013) Laparoscopic cholecystectomy: first, do no harm; second, take care of bile duct stones. Surg Endosc 27:1051–1054

  22. 22.

    de Mestral C, Rotstein OD, Laupacis A, Hoch JS, Zagorski B, Alali AS, Nathens AB (2014) Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Ann Surg 259:10–15

  23. 23.

    Aggarwal R, Crochet P, Dias A, Misra A, Ziprin P, Darzi A (2009) Development of a virtual reality training curriculum for laparoscopic cholecystectomy. Br J Surg 96:1086–1093

  24. 24.

    Sanford DE, Strasberg SM (2014) A simple effective method for generation of a permanent record of the critical view of safety during laparoscopic cholecystectomy by intraoperative “doublet” photography. J Am Coll Surg 218:170–178

  25. 25.

    Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101–125

  26. 26.

    Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ, Knuiman MW, Sheiner HJ, Edis A (1999) Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography—a population-based study. Ann Surg 229:449–457

  27. 27.

    Strasberg SM, Brunt LM (2010) Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 211:132–138

  28. 28.

    Gallagher M, Hares T, Spencer J, Bradshaw C, Webb I (1993) The nominal group technique: a research tool for general practice? Fam Pract 10:76–81

  29. 29.

    Dalkey NC (1967) Delphi. RAND Corporation, Santa Monica

  30. 30.

    Mishra A, Catchpole K, Dale T, McCulloch P (2008) The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc 22:68–73

  31. 31.

    Pucher PH, Aggarwal R, Darzi A (2014) Surgical ward round quality and impact on variable patient outcomes. Ann Surg 259:222–226

  32. 32.

    Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG (2003) Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 237:460–469

  33. 33.

    Feldman LS, Brunt LM, Fuchshuber P, Jones DB, Jones SB, Mischna J, Munro MG, Rozner MA, Schwaitzberg SD, Committee SF (2013) Rationale for the fundamental use of surgical Energy (FUSE) curriculum assessment: focus on safety. Surg Endosc 27:4054–4059

  34. 34.

    Wauben LS, Goossens RH, van Eijk DJ, Lange JF (2008) Evaluation of protocol uniformity concerning laparoscopic cholecystectomy in the Netherlands. World J Surg 32:613–620

  35. 35.

    Buddingh KT, Hofker HS, ten Cate Hoedemaker HO, van Dam GM, Ploeg RJ, Nieuwenhuijs VB (2011) Safety measures during cholecystectomy: results of a nationwide survey. World J Surg 35:1235–1241

  36. 36.

    Mealing NM, Banks E, Jorm LR, Steel DG, Clements MS, Rogers KD (2010) Investigation of relative risk estimates from studies of the same population with contrasting response rates and designs. BMC Med Res Methodol 10:26

  37. 37.

    Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN (2014) Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 370:1029–1038

  38. 38.

    Borchard A, Schwappach DL, Barbir A, Bezzola P (2012) A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Ann Surg 256:925–933

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Rajesh Aggarwal is a consultant for Applied Medical. Robert D. Fanelli is a consultant for EndoGastric Solutions and Cook Surgical, Inc. All other authors declare no financial ties or conflicts of interest.

Author information

Correspondence to Philip H. Pucher.

Additional information

On behalf of the SAGES Safe Cholecystectomy Task Force.


Appendix 1

See Table 4

Table 4 Detailed Delphi consensus results

Appendix 2

See Table 5

Table 5 Results of Delphi consensus to select top five factors relevant to training

Appendix 3

See Table 6

Table 6 Results of Delphi consensus to select top five factors relevant to assessment

Appendix 4

See Table 7

Table 7 Results of Delphi consensus to select top five factors relevant to research

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Pucher, P.H., Brunt, L.M., Fanelli, R.D. et al. SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surg Endosc 29, 3074–3085 (2015). https://doi.org/10.1007/s00464-015-4079-z

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  • Cholecystectomy
  • Patient safety
  • Consensus
  • Expert