Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future. A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one “ideal” laparoscopic operative report template following international input from the World Society of Emergency Surgery board. A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic. This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals’ medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC.

中文翻译：

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是时候为接受腹腔镜胆囊切除术的患者制定最小概要手术模板了：系统评价

尽管呼吁提高操作记录的准确性和价值，但很少有国际推荐的操作记录文档最低标准被描述。本研究对腹腔镜胆囊切除术 (LC) 的现有手术报告系统进行了系统评价，为未来制定了一个全面的概要手术报告模板。2021 年 6 月，使用 PubMed 版本的 Medline、Scopus 和 Web of Science 数据库对 2011 年 1 月 1 日至 2021 年 10 月 25 日的出版物进行了所有相关文章的搜索，使用关键字：腹腔镜胆囊切除术和手术笔记或手术笔记或形式或文件或报告或叙述或视听或概要或数字。两名审稿人（NOC，GMC) 独立评估每项已发表的研究，使用 ≥ 16 的 MINORS 分数进行比较， ≥ 10 用于纳入非比较。该系统评价遵循 PRISMA 指南并在 PROSPERO 注册。根据世界急诊外科学会理事会的国际意见，来自已发表数据的概要手术模板被同化为一个“理想的”腹腔镜手术报告模板。共审查了3567篇文章。在 MINORS 分级之后，选择了跨越 14 个国家和 4 个大洲的 25 项研究。22 项研究是前瞻性的。6/25 研究报告了手术程序文件的整体概述，另外 19 篇论文涉及 LC 的选择性手术方面。开发了一个独特的概要 LC 手术报告模板并翻译成中文/普通话，法语和阿拉伯语。该系统评价发现很少有涉及 LC 操作报告的出版物。提议的新模板可能会以数字方式与医院的医疗系统集成，并包括额外的叙述文本和视听数据。该模板可能有助于定义新的 OR（手术室）记录标准以及对接受 LC 患者护理的影响。