Laparoscopic Cholecystectomy Operation Notes (LaCON) project: protocol for developing consensus-derived synoptic reporting for laparoscopic cholecystectomy operation notes

Samenvatting

Abstract Background: Operation notes are essential documents for effective clinical communication, patient safety and medico-legal proceedings. However, inconsistencies and inaccuracies remain common challenges. Standardization through synoptic operative reporting has the potential to address these issues. Although laparoscopic cholecystectomy is one of the most common surgical procedures worldwide, there are no universal standards for its operative documentation. The Laparoscopic Cholecystectomy Operation Notes project aims to address these challenges by establishing international consensus on the content and structure of operative documentation for laparoscopic cholecystectomy and developing a standardized synoptic operation note template for global adoption. Methods: The project will use a multi-phase, mixed-methods, consensus-building approach. A scoping review will compile laparoscopic cholecystectomy components, followed by a modified thematic analysis to identify and organize data elements in preparation for voting. An expert panel of surgeons, gastroenterologists and radiologists will vote to achieve consensus on the essential data elements, their appropriate input types and the need for visual documentation (images or videos) in laparoscopic cholecystectomy operative documentation. Based on this consensus, a preliminary synoptic operation note template will be developed. Feedback will be sought from Patient and Public Involvement consultations, General Practitioners, and pilot testing with surgeons to refine and finalize the template for wider adoption. Discussion: A consensus-based synoptic operation note template for laparoscopic cholecystectomy is expected to enhance clinical communication and coordination, support consistent benchmarking and quality assurance and generate higher-fidelity data for research and real-world evidence. Clear, structured fields should reduce coding errors and improve medico-legal clarity. Registration: The study protocol has been pre-registered on the Open Science Framework (https://osf.io/d27uy) on 14 February 2025.