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Purpose: Recently, bail-out cholecystectomy (BOC) during laparoscopic cholecystectomy to avoid severe complications, such as vasculobiliary injury, has become widely used and increased in prevalence. However, current predictive factors or scoring systems are insufficient. Therefore, in this study, we aimed to test the validity of existing scoring systems and determine a suitable cutoff value for predicting BOC. Methods: We retrospectively assessed 305 patients who underwent laparoscopic cholecystectomy and divided them into a total cholecystectomy group (n = 265) and a BOC group (n = 40). Preoperative and operative findings were collected, and cutoff values for the existing scoring systems (Kama's and Nassar's) were modified using a prospectively maintained database. Results: The BOC rate was 13% with no severe complications. A logistic regression analysis revealed that the Kama's score (odds ratio, 0.93; 95% confidence interval 0.91–0.96; P < 0.01) was an independent predictor of BOC. A cutoff value of 6.5 points gave an area under the curve of 0.81, with a sensitivity of 87% and a specificity of 67%. Conclusions: Kama's difficulty scoring system with a modified cutoff value (6.5 points) is effective for predicting BOC. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic appendectomy is a common procedure and introduced early in general surgical training. How internal (i.e. surgeon's experience) or external (i.e. disease severity) may affect procedure performance is not well-studied. The aim of this study was to evaluate factors that may have an influence on the performance scores for surgical trainees. Methods: A prospective, observational cohort study of laparoscopic appendectomies performed by surgical trainees (experience < 4 years) operating under supervision. Trainers evaluated trainees' overall performance on a 6-point scale for proficiency. Perioperative data were recorded, including appendicitis severity, operating time and the overall difficulty of the procedure as assessed by the trainer. A "Challenging" procedure was defined as a combination of either/or "perforation" and "difficult". Trainees who had performed > 30 appendectomies were defined as "experienced". The trainees were asked if they had used simulation or web-based tools the week prior to surgery. Results: 142 procedure evaluation forms were included of which 19 (13%) were "perforated", 14 (10%) "difficult" and 24 (17%) "Challenging". Perforated appendicitis was strongly associated with procedure difficulty (OR 21.2, 95% CI 6.0–75.6). Experienced trainees performed "proficient" more often than non-experienced (OR 34.5, 95% CI 6.8–176.5). "Difficult" procedures were inversely associated with proficiency (OR 0.1, 95% CI 0.0–0.9). In "Challenging" procedures, identifying the appendix had lowest proficiency (OR 0.4, 95% CI 0.1–0.9). The procedures assessed as "difficult" had significantly longer operating time with a median (IQR) of 90 (75–100) min compared to 59 (25–120) min for the non-difficult (p < 0.001). Conclusion: Both internal and external factors contribute to the performance score. Perforated appendicitis, technical difficult procedures and trainee experience all play a role, but a "difficult" procedure had most overall impact on proficiency evaluation. [ABSTRACT FROM AUTHOR]

Introduction: Tokyo Guidelines 2018 (TG18) recommend early laparoscopic cholecystectomy (LC) for low‐risk acute cholecystitis (AC); however, some patients undergo delayed LC (DLC) after conservative treatment. DLC, influenced by chronic inflammation, is a difficult procedure. Previous studies on LC difficulty lacked objective measures. Recently, TG18 introduced a novel 25 findings difficulty score, which objectively assesses intraoperative factors. The purpose of this study was to use the difficulty score proposed in TG18 to identify and investigate the predictors of preoperative high‐difficulty cases of DLC for AC. Methods: We retrospectively reviewed 100 patients with DLC after conservative AC treatment. The surgical difficulty of DLC was evaluated using a difficulty score. Based on previous studies, the highest scores in each category were categorized as grades A–C. Results: The severity of AC was mild in 51 patients and moderate in 49. Surgical outcomes revealed a distribution of difficulty scores, with grade C indicating high difficulty, showing significant differences in operative time, blood loss, achieving a critical view of safety, bailout procedures, and postoperative hospital stay compared with grades A and B. Regarding the preoperative risk factors, multivariate analysis identified age >61 years (p =.008), body mass index >27.0 kg/m2 (p =.007), and gallbladder wall thickness >6.2 mm (p =.001) as independent risk factors for grade C in DLC. Conclusion: The difficulty score proposed in TG18 provides an objective framework for evaluating surgical difficulty, allowing for more accurate risk assessments and improved preoperative planning in DLC for AC. [ABSTRACT FROM AUTHOR]

The IMM (Institut Mutualiste Montsouris) difficulty classification for laparoscopic liver resection is based only on the type of surgical procedure. It is useful for assessing outcomes and setting benchmarks in a group sharing the same indications. There is, however, no left medial sectionectomy in the system. Its difficulty was evaluated using the same methodology as IMM with the data from a personal series. Furthermore, length of hospital stay was evaluated as the representative of short-term outcomes. IMM scores of our right and left hemihepatectomies, right anterior sectionectomy, and segment 7 or 8 segmentectomies are 3. That of left medial sectionectomies is 2, the same as right posterior sectionectomy and segment or less anatomical resections. Those of left lateral sectionectomy and partial resection are 0. The group with a score of 3 was divided into two groups—with and without extended hospital stays (extended only for right hemihepatectomies and right anterior sectionectomies). The difficulty of medial sectionectomy was positioned at the same level as posterior sectionectomy and segment or less anatomical resections. The result from the second evaluation may indicate that there are other factors with an impact on difficulty related to short-term outcomes, other than intraoperative surgical difficulty from the procedure itself. [ABSTRACT FROM AUTHOR]

Introduction: The Japanese difficulty score (JDS) categorizes laparoscopic hepatectomy into low, intermediate, and high complexity procedures, and correlates with operative and postoperative outcomes. We sought to perform a validation study to determine if the JDS correlates with operative and postoperative indicators of surgical complexity for patients undergoing robotic-assisted hepatectomy. Methods: Retrospective review of 657 minimally invasive hepatectomy procedures was performed between January 2008 through March 2019. Outcomes included operative time, estimated blood loss (EBL), blood transfusion, complications, post-hepatectomy liver failure (PHLF), length of stay, 30-day readmission, and 30-day and 90-day mortality. Patients were grouped based on JDS defined as: low (< 4), intermediate (4–6), and high (7 +) complexity procedures. Statistical comparisons were analyzed by ANOVA or χ2 test. Results: 241 of 657 patients underwent robotic-assisted resection. Of these patients, 137 were included in the analysis based on JDS: 25 low, 58 intermediate, and 54 high. High JDS was associated with more major resections (≥ 4 contiguous segments) versus minor resections (median JDS 8 vs. 5, P < 0.0001). High JDS was associated with significantly longer operative times, higher EBL, and more blood transfusions. High JDS was associated with higher rates of PHLF at 16.7%, compared with 5.2% intermediate and 0.0% low, (P = 0.018). Complication rates, 30-day readmissions, and mortality rates were similar between groups. Median LOS was longer in patients with high JDS compared with intermediate and low (4 days vs. 3 days vs. 2 days; P = 0.0005). Discussion: Higher JDS was associated with multiple indicators of operative complexity, including greater extent of resection, increased operative time, EBL, blood transfusion, PHLF, and LOS. This validation study supports the ability of the JDS to categorize patients undergoing robotic-assisted hepatectomy by complexity. [ABSTRACT FROM AUTHOR]

This study aimed to examine how genetic polymorphisms related to muscular strength and flexibility influence artistic gymnastic performance in an attempt to identify a novel polymorphism associated with flexibility. In study 1, the passive straight-leg-raise (PSLR) score and aromatase gene CYP19A1 rs936306 polymorphism, a key enzyme for estrogen biosynthesis, were assessed in 278 individuals. In study 2, athletes (281 gymnasts and 1908 other athletes) were asked about their competition level, and gymnasts were assessed using the difficulty score (D-score) for each event. Muscular strength- (ACTN3 R577X rs1815739 and ACE I/D rs4341) and flexibility-related (ESR1 rs2234693 T/C and CYP19A1 rs936306 C/T) genetic polymorphisms were analyzed. In study 1, males with the CYP19A1 CT + TT genotype showed significantly higher PSLR scores than those with the CC genotype. In study 2, male gymnasts with the R allele of ACTN3 R577X showed a correlation with the floor, rings, vault, and total D-scores. In addition, male gymnasts with the C allele of ESR1 T/C and T allele of CYP19A1 C/T polymorphisms were correlated with the pommel horse, parallel bars, horizontal bar, and total D-scores. Furthermore, genotype scores of these three polymorphisms correlated with the total D-scores and competition levels in male gymnasts. In contrast, no such associations were observed in female gymnasts. Our findings suggest that muscular strength- and flexibility-related polymorphisms play important roles in achieving high performance in male artistic gymnastics by specifically influencing the performance of events that require muscular strength and flexibility, respectively. Highlights Estrogen-related CYP19A1 polymorphism is a novel determinant of flexibility in males. Muscular strength- and flexibility-related polymorphisms play important roles in high performance in male artistic gymnastics. Genotypes of ACTN3 R577X, ESR1 rs2234693, and CYP19A1 rs936306 may contribute to training plan optimization and event selection in artistic gymnastics. [ABSTRACT FROM AUTHOR]

Simple Summary: It is essential to consider the specific impact that conversion can have in a context where MILR is so positively determinant, that is, hepatocellular carcinoma. It has not yet been specifically investigated what impact conversion may have in case of advanced cirrhosis, which is the central risk factor for specific postoperative complications and the context in which the loss of minimally invasive benefits can be particularly harmful. This study showed that conversion in the setting of advanced cirrhosis can be associated with non-inferior outcomes compared to compensated cirrhosis, provided careful patient selection is applied. Difficulty scoring systems may help in identifying the most appropriate candidates to maintain satisfactory outcomes, even in case of conversion, and become helpful in multidisciplinary treatment decisions. Background: Minimally invasive liver resections (MILRs) in cirrhosis are at risk of conversion since cirrhosis and complexity, which can be estimated by scoring systems, are both independent factors for. We aimed to investigate the consequence of conversion of MILR for hepatocellular carcinoma in advanced cirrhosis. Methods: After retrospective review, MILRs for HCC were divided into preserved liver function (Cohort-A) and advanced cirrhosis cohorts (Cohort-B). Completed and converted MILRs were compared (Compl-A vs. Conv-A and Compl-B vs. Conv-B); then, converted patients were compared (Conv-A vs. Conv-B) as whole cohorts and after stratification for MILR difficulty using Iwate criteria. Results: 637 MILRs were studied (474 Cohort-A, 163 Cohort-B). Conv-A MILRs had worse outcomes than Compl-A: more blood loss; higher incidence of transfusions, morbidity, grade 2 complications, ascites, liver failure and longer hospitalization. Conv-B MILRs exhibited the same worse perioperative outcomes than Compl-B and also higher incidence of grade 1 complications. Conv-A and Conv-B outcomes of low difficulty MILRs resulted in similar perioperative outcomes, whereas the comparison of more difficult converted MILRs (intermediate/advanced/expert) resulted in several worse perioperative outcomes for patients with advanced cirrhosis. However, Conv-A and Conv-B outcomes were not significantly different in the whole cohort where "advanced/expert" MILRs were 33.1% and 5.5% in Cohort A and B. Conclusions: Conversion in the setting of advanced cirrhosis can be associated with non-inferior outcomes compared to compensated cirrhosis, provided careful patient selection is applied (patients elected to low difficulty MILRs). Difficulty scoring systems may help in identifying the most appropriate candidates. [ABSTRACT FROM AUTHOR]

Introduction: While minimally invasive liver resections (MILR) have demonstrated advantages in improved post-operative recovery, widespread adoption is hampered by inherent technical difficulties. Our study attempts to analyze the role of anthropometric measures in MILR-related outcomes. Methods: Between 2012 and 2020, 676 consecutive patients underwent MILR at the Singapore General Hospital of which 565 met study criteria and were included. Patients were stratified based on Body Mass Index (BMI) as well as Standardized Liver Volumes (SLV). Associations between BMI and SLV to selected peri-operative outcomes were analyzed using restricted cubic splines. Results: A BMI of ≥ 29 was associated with increase in blood loss [Mean difference (MD) 69 mls, 95% CI 2 to 137] as well as operative conversions [Relative Risk (RR) 1.63, 95% CI 1.02 to 2.62] among patients undergoing MILR while a SLV of 1600 cc or higher was associated with an increase in blood loss (MD 30 mls, 95% CI 10 to 49). In addition, a BMI of ≤ 20 was associated with an increased risk of major complications (RR 2.25, 95% 1.16 to 4.35). The magnitude of differences observed in these findings increased with each unit change in BMI and SLV. Conclusion: Both BMI and SLV were useful anthropometric measures in predicting peri-operative outcomes in MILR and may be considered for incorporation in future difficulty scoring systems for MILR. [ABSTRACT FROM AUTHOR]

Introduction: The Iwate Score (IS) have not been well-validated for specific procedures, especially for right posterior sectionectomy (RPS). In this study, the utility of the IS was determined for laparoscopic (L)RPS and the effect of tumor location on surgical outcomes was investigated. Methods: Post-hoc analysis of 647 L-RPS performed in 40 international centers of which 596L-RPS cases met the inclusion criteria. Baseline characteristics and perioperative outcomes of patients stratified based on the Iwate score were compared to determine whether a correlation with surgical difficulty existed. A 1:1 Mahalanobis distance matching was utilized to investigate the effect of tumor location on L-RPS outcomes. Results: The patients were stratified into 3 levels of difficulty (31 intermediate, 143 advanced, and 422 expert) based on the IS. When using a stepwise increase of the IS excluding the tumor location score, only Pringle's maneuver was more frequently used in the higher surgical difficulty level (35.5%, 54.6%, and 65.2%, intermediate, advanced, and expert levels, respectively, Z = 3.34, p = 0.001). Other perioperative results were not associated with a statistical gradation toward higher difficulty level. 80 of 85 patients with a segment VI lesion and 511 patients with a segment VII lesion were matched 1:1. There were no significant differences in the perioperative outcomes of the two groups including open conversion, operating time, blood loss, intraoperative blood transfusion, postoperative stay, major morbidity, and mortality. Conclusion: Among patients undergoing L-RPS, the IS did not significantly correlate with most outcome measures associated with intraoperative difficulty and postoperative outcomes. Similarly, tumor location had no effect on L-RPS outcomes. [ABSTRACT FROM AUTHOR]

Background: Partial laparoscopic liver resection (LLR) is a procedure that can have varying levels of surgical difficulty depending on the tumor status and procedure. Therefore, we aimed to evaluate the surgical outcomes of partial LLR using a new resection classification system. Methods: From January 2009 to May 2021, 156 patients underwent LLR; of them, 87 patients who underwent pure partial LLR were included in this study. They were classified according to the IWATE criteria as the low (n = 56) and intermediate (n = 31) difficulty groups and reclassified according to the resection type as the edge (ER, n = 45), bowl-shaped (BSR, n = 27), and dome-shaped resection (DSR, n = 15) groups. The following surgical outcomes were comparatively analyzed among the groups: intraoperative blood loss, the operation time, and complication rates. Preoperative risk factors for intraoperative blood transfusion and complications were evaluated. Results: In the IWATE criteria-based analysis, the intermediate-difficulty group had significantly higher intraoperative blood loss (p = 0.005), operation time (p = 0.005), and Clavien–Dindo (CD) grade-based complication rates (CD grade 2 or higher, p = 0.03) than the low-difficulty group. When analyzing the resection type, the CD grade-based complication rate (p = 0.013) and surgical site infection (SSI, p = 0.005) were significantly higher and the postoperative hospitalization was significantly longer (p = 0.028) in the bowl-shaped resection (BSR) group than in the edge- (ER) and dome-shaped resection (DSR) groups. The tumor size (p = 0.011) and IWATE criteria score (p = 0.006) were independent risk factors for intraoperative blood transfusion in the multivariate analysis. The tumor depth (p = 0.011) and BSR (p = 0.002) were independent risk factors for complications of CD grade 2 or higher in the multivariate analysis. BSR was an independent risk factor for SSI in the multivariate analysis (p = 0.017). Conclusions: Resection type could predict the rate of postoperative complications, while the IWATE criteria could predict the intraoperative surgical difficulty. [ABSTRACT FROM AUTHOR]

Background: A difficulty score for laparoscopic adrenalectomy (LA) is lacking in the literature. A retrospective cohort study was designed to develop a preoperative "difficulty score" for LA. Methods: A multicenter study was conducted involving four Italian tertiary centers for adrenal disease. The population was randomly divided into two subsets: training group and validation one. A multicenter study was undertaken, including 964 patients. Patient, adrenal lesion, surgeon's characteristics, and the type of procedure were studied as potential predictors of target events. The operative time (pOT), conversion rate (cLA), or both were used as indicators of the difficulty in three multivariate models. All models were developed in a training cohort (70% of the sample) and validated using 30% of patients. For all models, the ability to predict complicated postoperative course was reported describing the area under the curve (AUCs). Logistic regression, reporting odds ratio (OR) with p-value, was used. Results: In model A, gender (OR 2.04, p = 0.001), BMI (OR 1.07, p = 0.002), previous surgery (OR 1.29, p = 0.048), site (OR 21.8, p < 0.001) and size of the lesion (OR 1.16, p = 0.002), cumulative sum of procedures (OR 0.99, p < 0.001), extended (OR 26.72, p < 0.001) or associated procedures (OR 4.32, p = 0.015) increased the pOT. In model B, ASA (OR 2.86, p = 0.001), lesion size (OR 1.20, p = 0.005), and extended resection (OR 8.85, p = 0.007) increased the cLA risk. Model C had similar results to model A. All scores obtained predicted the target events in validation cohort (OR 1.99, p < 0.001; OR 1.37, p = 0.007; OR 1.70, p < 0.001, score A, B, and C, respectively). The AUCs in predicting complications were 0.740, 0.686, and 0.763 for model A, B, and C, respectively. Conclusion: A difficulty score based on both pOT and cLA (Model C) was developed using 70% of the sample. The score was validated using a second cohort. Finally, the score was tested, and its results are able to predict a complicated postoperative course. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic liver resection (LLR) involves a difficult learning curve, for which multiple difficulty scores have been proposed to assist with safe adaptation. The IWATE Criteria is a 4-level difficulty score shown to correlate with conversion to open surgery, estimated blood loss (EBL), and operative time in Japanese and French cohorts. We set out to validate the IWATE Criteria in a North American cohort, describe the evolution of our LLR program, and analyze the IWATE Criteria's ability to predict conversion to open surgery. Methods: Patients that underwent LLR between January 2006 and December 2019 were selected from a prospectively maintained database. Difficulty outcomes, including conversion to open surgery, EBL, operative time, and post-operative complications were analyzed according to IWATE difficulty level, both overall and between chronological eras. The IWATE Criteria's ability to predict conversion to open surgery was assessed with a receiver operating characteristic (ROC) analysis. Results: A total of 426 patients met inclusion criteria. Operative time, EBL, and conversion to open surgery increased in concordance with low to advanced IWATE difficulty. ROC analysis for conversion to open surgery demonstrated an overall area under the curve (AUC) of 0.694. Predictive performance was superior during the first two eras, with AUCs of 0.771 and 0.775; predictive value decreased as the LLR program gained experience, with AUCs of 0.708 and 0.551 for eras three and four. Conclusions: This study validated the IWATE Criteria in a North American population distinct from previous Japanese and French cohorts, based on its correlation with operative time, EBL, and conversion to open surgery. The IWATE Criteria may be of utility for identification of LLR cases appropriate for surgeon experience, as well as determination of laparoscopic feasibility. Interval difficulty score recalibration may be warranted as surgeon perception of difficulty evolves. [ABSTRACT FROM AUTHOR]

Introduction: The presence of previous abdominal surgery (PAS) has traditionally been considered to add difficulty to and increase risk of complications of laparoscopic procedures. This study aims to analyse the impact of non-liver-related PAS on the difficulty of minimally invasive liver resections (MILRs). Materials and methods: After exclusion of patients with concomitant major surgical procedures as well as previous liver resections, 515 consecutive patients undergoing MILR in Singapore General Hospital from 2006 to 2019 were analysed, consisting of 161 MILR in patients with previous abdominal surgery (WPAS) and 354 MILR in patients without previous abdominal surgery (WOPAS). Propensity score-matched (PSM) comparison was performed between WPAS and WOPAS groups. In addition, subgroup analysis was made comparing previous upper or lower abdominal surgery and open versus minimally invasive approach of PAS. Outcomes measured include those associated with operative difficulty such as open conversion rates, operative time, blood loss, as well as morbidity and mortality rates. Results: MILR outcomes in patients WPAS are not inferior to those WOPAS. Overall open conversion rate was 8.2%, higher in patients WOPAS compared to patients WPAS (11.9% versus 3.5%, p = 0.015). Operating time (p = 0.942), blood loss (p = 0.063), intraoperative blood transfusion (p = 0.750), length of hospital stay (p = 0.206), morbidity (p = 0.217) and 30- and 90-day mortality (p = 1 & p = 0.367) were comparable between the two groups and subgroup analysis. Conclusion: Outcomes of MILR in patients with previous non-liver-related abdominal surgery are not inferior to patients without previous abdominal surgery. [ABSTRACT FROM AUTHOR]

The purpose of this study was to give information and provide to coaches and junior gymnasts some trends and important guidelines for exercises that are key to the development of gymnasts at an earlier age. Recordings of exercises from the rings' finalists were taken and used. An analysis of the content of the combinations was made by two international category judges, according to the current Code of Points. The results showed that elements with C difficulty are most common in the finalist's routines. The average difficulty score was 4,538, and execution score was 8,843. The routine with the highest recognized difficulty was performed by a gymnast from China with a score of 4,8. The most common element was from group I - Kip and swing elements & swings through or to handstand. All of the considered routines contained Yamawaki, Jonasson, swing fwd. with straight arms to handstand (2 s.), and giant swing to handstand with straight arms (2 s.). Coaches and junior gymnasts should try to increase the D score above 4,5 by including elements with a higher score from groups II and III, in addition to decreasing deduction of elements in routines below 1,2. [ABSTRACT FROM AUTHOR]

Introduction: The impact of liver cirrhosis on the difficulty of minimal invasive liver resection (MILR) remains controversial and current difficulty scoring systems do not take in to account the presence of cirrhosis as a significant factor in determining the difficulty of MILR. We hypothesized that the difficulty of MILR is affected by the presence of cirrhosis. Hence, we performed a 1:1 matched-controlled study comparing the outcomes between patients undergoing MILR with and without cirrhosis including the Iwate system and Institut Mutualiste Montsouris (IMM) system in the matching process. Methods: Between 2006 and 2019, 598 consecutive patients underwent MILR of which 536 met the study inclusion criteria. There were 148 patients with cirrhosis and 388 non-cirrhotics. One-to-one coarsened exact matching identified approximately exact matches between 100 cirrhotic patients and 100 non-cirrhotic patients. Results: Comparison between MILR patients with cirrhosis and non-cirrhosis in the entire cohort demonstrated that patients with cirrhosis were associated with a significantly increased open conversion rate, transfusion rate, need for Pringles maneuver, postoperative, stay, postoperative morbidity and postoperative 90-day mortality. After 1:1 coarsened exact matching, MILR with cirrhosis were significantly associated with an increased open conversion rate (15% vs 6%, p = 0.03), operation time (261 vs 238 min, p < 0.001), blood loss (607 vs 314 mls, p = 0.002), transfusion rate (22% vs 9%, p = 0.001), need for application of Pringles maneuver (51% vs 34%, p = 0.010), postoperative stay (6 vs 4.5 days, p = 0.004) and postoperative morbidity (26% vs 13%, p = 0.029). Conclusion: The presence of liver cirrhosis affected both the intraoperative technical difficulty and postoperative outcomes of MILR and hence should be considered an important parameter to be included in future difficulty scoring systems for MILR. [ABSTRACT FROM AUTHOR]

Background: Difficulty scores (DSs) have been proposed to rate laparoscopic liver resection (LLR) technical difficulty increasing surgical safety. The aim of the study was to validate three DSs (Hasegawa, Halls and Kawaguchi) and compare their ability to predict technical difficulty and postoperative outcomes.Materials and Methods: All patients who underwent LLR from January 2006 to January 2019 were analyzed. Exclusion criteria were cyst fenestrations, thermal ablation, missing data for the computation of the DS and a follow-up < 90 days.Results: The population comprised 300 patients. The DS distribution in the study population was: Halls low 55 (18.3%), moderate 82 (27.3%), high 111 (37%) and extremely high 52 (17.3%); Hasegawa low 130 (43.3%), medium 105 (35%) and high 65 (21.7%); Kawaguchi Grade I 194 (64.7%), Grade II 47 (15.7%) and Grade III 59 (19.7%). Hasegawa and Kawaguchi showed the strongest correlation (r = 0.798, p < 0.001). Technical complexity, evaluated using the Pringle maneuver, Pringle time, blood loss and operative time, increased significantly with Hasegawa and Kawaguchi score classes (p < 0.001 for all comparisons). None of the scores properly stratified postoperative complications. The highest Kawaguchi (23.7% grade III vs. 13.7% grades I and II, p = 0.057) and Hasegawa (24.6% high vs. 13.2% low/medium, p = 0.025) classes had a higher overall morbidity rate than medium-low ones.Conclusions: Kawaguchi and Hasegawa scores predicted LLR's technical difficulty. None of the scores discriminated the postoperative complication risk of low classes compared with medium ones. [ABSTRACT FROM AUTHOR]

Background: Recently, the minimally invasive surgical approach has been available for performing liver resections (LRs) with laparoscopic and robotic techniques. The robotic approach for LRs seems to overcome several laparoscopic limitations, which is a valid alternative when performed in high volume and specialized centers. Laparoscopic difficulty score systems (DSSs) should serve to guide the surgeon's choice in the best surgical approach to adopt for every single patient, giving the possibility to switch to the open approach when needed. To this day, no specific robotic difficulty scores exist. The aim of our study was to verify the feasibility of applying these scores and related updates on robotic LRs performed in our Institute. Materials and Methods: Out of a total of 683 LRs performed from June 2010 to July 2019, 60 were performed through using a mini invasive approach and of these 18 were performed robotically. The Ban DSS and subsequently the modified Iwate DSS were applied to our cases. Results: Based on our findings, applying the DSS we divided our series into two groups: a low difficulty level group (1-3) made up of 5 patients, and an intermediate difficulty level group (4-6) consisting of 13 patients. Average Ban DSS and subsequently updated score system results were 4.6 ± 1.5 points (range 2-6) for both scores. Conclusions: Difficulties were encountered in applying the score when simultaneous multiple wedge resections were performed. The laparoscopic DSS is applicable to robotic LRs with some limitations due to the peculiarity of the two different minimally invasive approaches. A specific robotic difficulty rating score could be necessary to include these elements. [ABSTRACT FROM AUTHOR]

Background: The development of robotic system may help to relieve the difficulties encountered during laparoscopic hepatectomy. A difficulty scoring system (DSS) was developed to assess the difficulty of various laparoscopic liver resection procedures. The aim of this study is to explore if the DSS is applicable in robotic hepatectomy and to compare the outcomes of robotic hepatectomy and laparoscopic hepatectomy among different difficulty levels.Methods: Clinical data from all consecutive patients who underwent robotic and conventional laparoscopic hepatectomy at the Prince of Wales Hospital, Hong Kong, were prospectively collected and reviewed. The difficulty level of operations was graded using the DSS. Perioperative outcomes of robotic and conventional laparoscopic hepatectomy were compared at each difficulty level.Results: A total of 107 and 94 patients underwent robotic and laparoscopic hepatectomy during the study period, respectively. Among them, 16 and 2 patients were operated for recurrent pyogenic cholangitis, respectively, and were excluded because no mark for tumour location can be assigned. For robotic hepatectomy, a higher DSS was significantly correlated with higher minor complication rate (p = 0.001), more intraoperative blood loss (p = 0.002), longer operation time (p < 0.001) and longer post-operative hospital stay (p < 0.001). The mean DSS scores of robotic and laparoscopic hepatectomy were 4.5 and 3.6, respectively. (p = 0.004). For cases with low (DSS 1-3) and intermediate (DSS 4-6) difficulty level, there was no significant difference in operative blood loss, operation time and overall complications rate. Only 2 cases (2.2%) with high difficulty level were operated with laparoscopic approach while 20% of patients operated with robotic approach had DSS > 6.Conclusions: DSS significantly correlated with surgical outcomes in patient who underwent robotic hepatectomy. Perioperative outcomes following robotic and conventional laparoscopic hepatectomy were similar in cases with low and intermediate difficulty. However, robotic system allowed minimally invasive approach in cases with higher difficulty level. [ABSTRACT FROM AUTHOR]

Background: Technological innovations have made it possible to use laparoscopic liver resection in cases with pre-existing adhesions or cicatricial changes. However, laparoscopic repeat liver resection (LRLR) still represents a challenge for surgeons, especially in case of previous open liver surgery. This study evaluated the outcomes of LRLR after open liver resection (OLR) in cases of recurrent liver cancer. Materials and Methods: A total of 62 patients who underwent laparoscopic minor liver resection at our institution between September 2012 and September 2016 were retrospectively divided into an LRLR group (n = 13) and a laparoscopic primary liver resection group (LPLR; n = 49). The two groups were compared in terms of patient demographics, surgical procedures and short-term outcomes. Recurrence-free survival (RFS) and overall survival (OS) were compared for patients with hepatocellular carcinoma (HCC) or colorectal liver metastases (CRLMs). Results: There was a significant intergroup difference in the hepatitis virus background, although the two groups' primary histology and pre-operative liver function were comparable. The two groups had statistically similar values for extent of resection, operative time, estimated blood loss, transfusion requirement, conversion to laparotomy, post-operative complications, surgical margins, time to oral intake and hospital stay. No significant differences were detected when we stratified the cases according to low and intermediate difficulty. Furthermore, there were no intergroup differences in RFS or OS in the two groups for patients with HCC and CRLM. Conclusions: The findings suggest that minor LRLR after OLR is safe and comparable with minor LPLR in the present study. [ABSTRACT FROM AUTHOR]

Objective(s): The technical complexity of laparoscopic liver resection (LLR) poses unique challenges distinct from open surgery. An objective scoring system was developed that preoperatively quantifies the difficulty of LRR to help guide surgeon decision-making regarding the feasibility and safety of minimally invasive approaches. The aim of this multiinstitutional study was to externally validate this scoring system.Methods: Patients who underwent LLR at two institutions were reviewed. LLR difficulty score (LDS) was calculated based on patient, tumor, and anatomic characteristics by two independent, blinded hepatobiliary surgeons. Surrogates of case complexity (e.g., conversion rate, operative time) were used for validation of this index.Results: From 2006 to 2016, 444 LLR were scored as low (n = 94), intermediate (n = 98), and high difficulty (n = 152) with respective conversion rates of 5.3%, 15.7%, and 25%. Cases of higher LDS correlated with larger mean blood loss (203 ml vs. 331 ml vs. 635 ml). Mean operative and Pringle maneuver used were associated with increasing LDS (155 min vs. 202 min vs. 315 min and 14.4% vs. 29.7% vs. 45.1% respectively). These operative surrogates of difficulty correlated significantly with the LDS (all p < 0.0001).Conclusions: This comprehensive external validation of the LDS is robust and applicable in diverse patient populations. This LDS serves as a useful objective predictor of technical difficulty for LLR to help surgeons in selecting patients according to their individual operative experience and is valuable for preoperative risk estimation and stratification in randomized trials. [ABSTRACT FROM AUTHOR]

The card game 24 is a mathematical game that traditionally engages elementary students to practice their mental computational skills. In this paper, we use probability to formulate and explore the game. We create score of difficulty level for solvable card combination set under various setup of game rules. Based on our findings, we create new playing rules and provide suggestions for different levels of players. Our results may serve as guidelines on introducing the game 24 into the practice of math education. [ABSTRACT FROM PUBLISHER]

Background. A knowledge of the composition of competition elite gymnasts routines gives us a perspective of the evolution of gymnastics. Aim. The aim of this study is to try to understand if there is a common profile in the choice of difficulty elements in different body groups in gymnasts from different countries and/or from different "training schools". Methods. In this study, there were observed 70 different routines, from 23 different countries in 4 different continents, which have competed at the 2007 and 2008 Portimão World Cup Series (PWC). All the groups performed two different routines, one with 5 ropes and the other with 3 hoops and 4 clubs. To analyse the difficulty elements we used competitions forms provided in advance to the competition organisation. We used the competition forms instead of films because in this way the analysis would not be affected by mistakes made by the group during the competition. The official classification used in the FIG (Gymnastics International Federation) Code of Points (FIG, 2005-2008) was used to organise different elements. It classifies the body difficulties in 5 categories: Jumps/Leaps, Balances, Pivots, Flexibility/Waves and Exchanges. Results. The analysis of the 2007 and 2008 results showed that in the Jumps and for both routines, all groups preferred performing difficulties with different kinds of jeté with turn. In the balances category, the balance with horizontal trunk and the balances with different positions of the free leg were the most performed in both competitions. The most frequently used pivots were the pivots with the leg high (in front or side) for the two different types of routines in 2007. However, in PWC 2008, the fouettés were the most frequently used pivot in both routines. The preferred flexibility/wave elements used in the sample observed were the splits with the horizontal positions. The results show that the majority of the exchange elements were performed without body difficulty elements. However, when they include them, the groups chose jumps in both types of routine and in both competitions. Conclusions. In general a profile for each kind of apparatus could be designed and to compose the difficulty elements, the groups observed, demonstrated a preference for jumps and flexibility/waves in both routines and in both years (2007 and 2008). [ABSTRACT FROM AUTHOR]

Background: To investigate the feasibility of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC), we compared the outcome between LLR and conventional open liver resection (OLR) in patient groups with different IWATE criteria difficulty scores (DS). Methods: We retrospectively reviewed 607 primary HCC patients (LLR: 81, OLR: 526) who underwent liver resection in Linkou Chang Gung Memorial hospital from 2012 to 2019. By using 1:1 propensity score-matched (PSM) analysis, their baseline characteristics and the DS stratified by the IWATE criteria were matched between the LLR and OLR. Their perioperative and oncologic outcomes were compared. Results: After 1:1 PSM, 146 patients (73 in LLR, 73 in OLR) were analyzed. Among them, 13, 41, 13 and 6 patients were classified as low, intermediate, advanced and expert DS group, respectively. Compared to OLR, the LLR had shorter hospital stay (9.4 vs. 11.5 days, p = 0.071), less occurrence of surgical complications (16.4% vs. 30.1%, p = 0.049), lower rate of hepatic inflow control (42.5% vs. 65.8%, p = 0.005), and longer time of inflow control (70 vs. 51 min, p = 0.022). The disease-free survival (DFS) and overall survivals were comparable between the two groups. While stratified by the DS groups, the LLR tended to have lower complication rate and shorter hospital stay than OLR. The DFS of LLR in the intermediate DS group was superior to that of the OLR (p = 0.020). In the advanced and expert DS groups, there were no significant differences regarding outcomes between the two groups. Conclusion: We have demonstrated that with sufficient experience and technique, LLR for HCC is feasible and the perioperative outcome is favorable. Based on the current study, we suggest LLR should be a standard procedure for HCC with low or intermediate difficulty. It can provide satisfactory postoperative recovery and comparable oncological outcomes. Further larger scale prospective studies are warranted to validate our findings. [ABSTRACT FROM AUTHOR]