Abstract / Summary
Abstract Purpose This study aims to develop a standardised grading scale for case difficulty based on objective, visually observable criteria, thereby enhancing its utility for broader surgical education and research purposes. Methods Eighty de-identified LC videos were reviewed by three expert hepatopancreatobiliary surgeons. Spearman correlation analysis was used to eliminate redundant variables, and multivariate regression identified independent predictors of "severe" difficulty. Points were assigned based on odds ratios to create a weighted scoring instrument, which was validated using Receiver Operating Characteristic curves. Results Interrater agreement demonstrated five criteria achieving ‘excellent’ agreement and four showing ‘good’ agreement, with no criteria classified as ‘poor’. Significant independent predictors for ‘severe’ difficulty included 100% adhesion burying gallbladder (OR 29.3, p = 0.016), inability to grasp the gallbladder (OR 21.3, p = 0.029), and necessity for decompression (OR 59.7, p < 0.001). Cases classified as more difficult correlated with higher incidence of wall thickening (86.7% vs 5.6%, p < 0.001), exudate/gangrene (60% vs 0, p < 0.001), impacted stones (26.7% vs 0, p < 0.001), and inability to grasp (46.7% vs 0, p < 0.001). The scoring tool achieved an ROC AUC of 0.83 at a cutoff point of 3 for predicting ‘severe’ cases and an ROC AUC of 0.76 at a cutoff point of 1 for identifying ‘moderate’ cases. Conclusions This study established a statistically weighted, point-based scoring instrument for grading LC difficulty. By providing an objective and reproducible framework based on intraoperative video features, the tool facilitates standardised performance auditing, and the potential for future integration with automated artificial intelligence grading algorithms.