title: The "right" way is not always popular: comparison of surgeons' perceptions during laparoscopic cholecystectomy for acute cholecystitis among experts from Japan, Korea and Taiwan.
abstract: BACKGROUND
  Generally, surgeons' perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces.
  
  
  METHODS
  A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200-499, 500-999, and ≥1,000).
  
  
  RESULTS
  The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the "critical view of safety" technique, identification of Rouvière's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC.
  
  
  CONCLUSIONS
  Even among experts, surgeons' perceptions during LC are workplace-dependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence.
authors.affiliation: Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Taizo
authors.initials: T
authors.lastname: Hibi
authors.affiliation: Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan.
authors.forename: Yukio
authors.initials: Y
authors.lastname: Iwashita
authors.affiliation: Department of Clinical Statistics and Data Management, Oita University Faculty of Medicine, Oita, Japan.
authors.forename: Tetsuji
authors.initials: T
authors.lastname: Ohyama
authors.affiliation: Department of Surgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan.
authors.forename: Goro
authors.initials: G
authors.lastname: Honda
authors.affiliation: Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Chiba, Japan.
authors.forename: Masahiro
authors.initials: M
authors.lastname: Yoshida
authors.affiliation: Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.
authors.forename: Tadahiro
authors.initials: T
authors.lastname: Takada
authors.affiliation: Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Korea.
authors.forename: Ho-Seong
authors.initials: HS
authors.lastname: Han
authors.affiliation: Division of General Surgery, Lin-Kou Chang Gung Memorial Hospital, Tauyuan, Taiwan.
authors.forename: Tsann-Long
authors.initials: TL
authors.lastname: Hwang
authors.affiliation: Department of Surgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Shinya
authors.affiliation: Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan.
authors.forename: Kenji
authors.initials: K
authors.lastname: Suzuki
authors.affiliation: Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan.
authors.forename: Akiko
authors.initials: A
authors.lastname: Umezawa
authors.affiliation: Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Korea.
authors.forename: Yoo-Seok
authors.initials: YS
authors.lastname: Yoon
authors.affiliation: Department of Surgery, Konyang University Hospital, Daejeon, Korea.
authors.forename: In-Seok
authors.initials: IS
authors.lastname: Choi
authors.affiliation: Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan.
authors.forename: Wayne Shih-Wei
authors.initials: WS
authors.lastname: Huang
authors.affiliation: Department of Surgery and Department of Electrical Engineering, Far-Eastern Memorial Hospital and Yuan Ze University, New Taipei City, Tauyuan, Taiwan.
authors.forename: Kuo-Hsin
authors.initials: KH
authors.lastname: Chen
authors.affiliation: Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.
authors.forename: Fumihiko
authors.initials: F
authors.lastname: Miura
authors.affiliation: Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan.
authors.forename: Manabu
authors.initials: M
authors.lastname: Watanabe
authors.affiliation: Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Yuta
authors.initials: Y
authors.lastname: Abe
authors.affiliation: Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan.
authors.forename: Takeyuki
authors.initials: T
authors.lastname: Misawa
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan.
authors.forename: Yuichi
authors.initials: Y
authors.lastname: Nagakawa
authors.affiliation: Department of Surgery, Yonsei University Gangnam Severance Hospital, Seoul, Korea.
authors.forename: Dong-Sup
authors.initials: DS
authors.lastname: Yoon
authors.affiliation: Department of Surgery, Seoul National University Hospital, Seoul, Korea.
authors.forename: Jin-Young
authors.initials: JY
authors.lastname: Jang
authors.affiliation: Department of Surgery, Chonbuk National University Hospital, Jeonju, Korea.
authors.forename: Hee Chul
authors.initials: HC
authors.lastname: Yu
authors.affiliation: Department of Surgery, Keimyung University Dongsan Medical Center, Daegu, Korea.
authors.forename: Keun Soo
authors.initials: KS
authors.lastname: Ahn
authors.affiliation: Department of Surgery, University of Ulsan College of Medicine & Asan Medical Center, Seoul, Korea.
authors.forename: Song Cheol
authors.initials: SC
authors.lastname: Kim
authors.affiliation: Department of Surgery, Chungnam National University Hospital, Daejeon, Korea.
authors.forename: In Sang
authors.initials: IS
authors.lastname: Song
authors.affiliation: Department of Surgery, Eulji University Hospital, Daejeon, Korea.
authors.forename: Ji Hoon
authors.initials: JH
authors.lastname: Kim
authors.affiliation: Department of Surgery, Yeungnam University, Daegu, Korea.
authors.forename: Sung Su
authors.initials: SS
authors.lastname: Yun
authors.affiliation: Department of Surgery, Sungkyunkwan University, Seoul, Korea.
authors.forename: Seong Ho
authors.initials: SH
authors.lastname: Choi
authors.affiliation: Division of General Surgery, Lin-Kou Chang Gung Memorial Hospital, Tauyuan, Taiwan.
authors.forename: Yi-Yin
authors.initials: YY
authors.lastname: Jan
authors.affiliation: Division of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
authors.forename: Shyr-Ming
authors.initials: SM
authors.lastname: Sheen-Chen
authors.affiliation: Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan.
authors.forename: Yan-Shen
authors.initials: YS
authors.lastname: Shan
authors.affiliation: Department of Surgery, Yuan's General Hospital, Kaohsiung, Taiwan.
authors.forename: Chen-Guo
authors.initials: CG
authors.lastname: Ker
authors.affiliation: Division of General Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
authors.forename: De-Chuan
authors.initials: DC
authors.lastname: Chan
authors.affiliation: Department of Surgery, Taicuhg-Veterans General Hospital, Taichung, Taiwan.
authors.forename: Cheng-Chung
authors.initials: CC
authors.lastname: Wu
authors.affiliation: Department of Surgery, Musashino Tokushukai Hospital, Tokyo, Japan.
authors.forename: Naoyuki
authors.initials: N
authors.lastname: Toyota
authors.affiliation: Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.
authors.forename: Ryota
authors.initials: R
authors.lastname: Higuchi
authors.affiliation: Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan.
authors.forename: Yoshiharu
authors.initials: Y
authors.lastname: Nakamura
authors.affiliation: Department of Surgery, Nippon Medical School, Tokyo, Japan.
authors.forename: Yoshiaki
authors.initials: Y
authors.lastname: Mizuguchi
authors.affiliation: Department of Surgery, Kansai Rosai Hospital, Hyogo, Japan.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Takeda
authors.affiliation: Department of General and Pancreatic Surgery, Quality and Safety in Healthcare, Fujita Health University, Aichi, Japan.
authors.forename: Masahiro
authors.initials: M
authors.lastname: Ito
authors.affiliation: Department of Surgery, Nagoya Daini Red Cross Hospital, Aichi, Japan.
authors.forename: Shinji
authors.initials: S
authors.lastname: Norimizu
authors.affiliation: Department of Surgery, Kameda Medical Center, Chiba, Japan.
authors.forename: Shigetoshi
authors.initials: S
authors.lastname: Yamada
authors.affiliation: Department of Surgery, Tohoku Rosai Hospital, Miyagi, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Matsumura
authors.affiliation: Department of Digestive Surgery, Toranomon Hospital, Tokyo, Japan.
authors.forename: Junichi
authors.initials: J
authors.lastname: Shindoh
authors.affiliation: Department of Surgery, Nakagami Hospital, Okinawa, Japan.
authors.forename: Hiroki
authors.initials: H
authors.lastname: Sunagawa
authors.affiliation: Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Gocho
authors.affiliation: Laparoscopic Surgery Center, Tokai Hospital, Aichi, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Hasegawa
authors.affiliation: Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
authors.forename: Toshiki
authors.initials: T
authors.lastname: Rikiyama
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan.
authors.forename: Naohiro
authors.initials: N
authors.lastname: Sata
authors.affiliation: Chiba Tokushukai Hospital, Chiba, Japan.
authors.forename: Nobuyasu
authors.initials: N
authors.lastname: Kano
authors.affiliation: Oita University, Oita, Japan.
authors.forename: Seigo
authors.initials: S
authors.lastname: Kitano
authors.affiliation: Department of Surgery, Tohoku Rosai Hospital, Miyagi, Japan.
authors.forename: Hiromi
authors.initials: H
authors.lastname: Tokumura
authors.affiliation: Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Fukuoka, Japan.
authors.forename: Yuichi
authors.initials: Y
authors.lastname: Yamashita
authors.affiliation: Department of Surgery, Sanno Hospital, International University of Health and Welfare, Tokyo, Japan.
authors.forename: Goro
authors.initials: G
authors.lastname: Watanabe
authors.affiliation: Japanese Red Cross Miyagi Blood Center, Miyagi, Japan.
authors.forename: Kunitoshi
authors.initials: K
authors.lastname: Nakagawa
authors.affiliation: Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan.
authors.forename: Taizo
authors.initials: T
authors.lastname: Kimura
authors.affiliation: Department of Surgery, Teikyo University School of Medicine, University Hospital, Mizonokuchi, Kanagawa, Japan.
authors.forename: Tatsuo
authors.initials: T
authors.lastname: Yamakawa
authors.affiliation: Department of Surgery, Ageo Central General Hospital, Saitama, Japan.
authors.forename: Go
authors.initials: G
authors.lastname: Wakabayashi
authors.affiliation: Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan.
authors.forename: Itaru
authors.initials: I
authors.lastname: Endo
authors.affiliation: Graduate School of Medicine, Chiba University, Chiba, Japan.
authors.forename: Masaru
authors.initials: M
authors.lastname: Miyazaki
authors.affiliation: Department of Surgery, Yuan's General Hospital, Kaohsiung, Taiwan.
authors.forename: Masakazu
authors.initials: M
authors.lastname: Yamamoto
mesh_terms: D001291:Attitude of Health Personnel; D016063:Blood Loss, Surgical / Q000503:physiopathology*; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods*; D041881:Cholecystitis, Acute / Q000175:diagnosis / Q000601:surgery*; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D038622:Internationality; D007564:Japan; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods; D008297:Male; D061646:Operative Time; D061214:Patient Safety / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D056910:Republic of Korea; D066231:Surgeons / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D013624:Taiwan
keywords: Acute cholecystitis; Critical view of safety; Laparoscopic cholecystectomy; SS-Inner theory; Surgical difficulty