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 Table of Contents     
Year : 2016  |  Volume : 12  |  Issue : 4  |  Page : 321-324

Quality of information available over internet on laparoscopic cholecystectomy

Department of Surgery, University of Colombo, Colombo, Sri Lanka

Date of Submission17-Oct-2015
Date of Acceptance02-Nov-2015
Date of Web Publication8-Sep-2016

Correspondence Address:
Jayaweera Muhandiramge Uthpala Jayaweera
Department of Surgery, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8
Sri Lanka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-9941.186691

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 ¤ Abstract 

Background: The purpose of this study was to evaluate the quality of information available on the internet to patients undergoing laparoscopic cholecystectomy. Materials and Methods: The sources of information were obtained the keyword 'laparoscopic cholecystectomy', from internet searches using Google, Bing, Yahoo!, Ask and AOL search engines with default settings. The first 50 web links were evaluated for their accessibility, usability and reliability using the LIDA tool (validation instrument for healthcare websites by Minervation).The readability of the websites was assessed by using the Flesch Reading Ease Score (FRES) and the Gunning Fog Index (GFI). Results: Of the 250 links, 90 were new links. Others were repetitions, restricted access sites or inactive links. The websites had an average accessibility score of 52/63 (83.2%; range 40-62), a usability score of 39/54 (73.1%; range 23-49) and a reliability score of 14/27 (51.6%; range 5-24). Average FRES was 41.07 (4.3-86.4) and average GFI was 11.2 (0.6-86.4). Discussion and Conclusion: Today, most people use the internet as a convenient source of information. With regard to health issues, the information available on the internet varies greatly in accessibility, usability and reliability. Websites appearing at the top of the search results page may not be the most appropriate sites for the target audience. Generally, the websites scored low on reliability with low scores on content production and conflict-of-interest declaration. Therefore, previously evaluated references on the World Wide Web should be given to patients and caregivers to prevent them from being exposed to commercially motivated or inaccurate information.

Keywords: Healthcare, information dissemination, internet, laparoscopic cholecystectomy, quality assurance

How to cite this article:
Jayaweera JM, De Zoysa MI. Quality of information available over internet on laparoscopic cholecystectomy. J Min Access Surg 2016;12:321-4

How to cite this URL:
Jayaweera JM, De Zoysa MI. Quality of information available over internet on laparoscopic cholecystectomy. J Min Access Surg [serial online] 2016 [cited 2022 Jan 27];12:321-4. Available from:

 ¤ Introduction Top

The widespread use of the internet by the community has led to new challenges for medical practitioners.[1],[2] Information available over the internet may be useful in enhancing the doctor-patient relationship.[2],[3]

Anyone has the freedom to publish information on the internet. Therefore, there is a possibility of this information being incorrect.[4],[5],[6] It is important to assess the quality of this information, as incorrect information could mislead the public. At present there are several tools used to assess the healthcare information on the internet. The LIDA tool (Minervation) is a validated method of assessing healthcare websites. It is based on three important areas, namely, accessibility, usability and reliability.[7]

Search engines are most frequently used to access information over the internet.[8] Usage characteristics of websites in USA can be obtained from the Quantcast rank [9] of the website. According to it, the five most used web search engines are Google, Bing, Yahoo! search, Ask and AOL Search. Usually, searches reveal a large number of links. But there is a high likelihood of a general user only visiting the links appearing at the top of a web search.[10] Unfortunately, a high rank does not guarantee the reliability or relevance of the website.

Websites targeting the public should be structured in such a manner that the message is clearly conveyed to the targeted audience.[11] Giving information in simple language is very important in increasing the understanding of the public. Readability tests indicate how easily a paragraph is understood on reading.[12] The Flesch Reading Ease Score (FRES) and the Gunning Fog Index (GFI) are two such tests, developed to assess the readability of a paragraph. The FRES rates English text on a 100-point scale and indicates the level of comprehension. Paragraphs that are easier to read show higher scores, while difficult passages show lower scores. The FRES can be calculated by using following formula:

206.835-1.015(Total words/total sentences)-84.6(total syllables/total words)[13]

The GFI estimates the number of years of school education required to understand the English text on first reading. It is based on sentence length and difficult words within the sentence. Usually, academic papers have >15 GFI values.[13] The GFI is calculated as follows: Grade level = 0.4 (average sentence length + percentage of hard words). Therefore, short sentences written in simple English achieve the best scores.[13]

Cholecystectomy is one of the most commonly performed abdominal operations worldwide. At present, the majority of cholecystectomies are performed laparoscopically. It is an operation that is safe in the vast majority of patients. A few notable complications include bleeding, bile leakage and bile duct injuries.[14] Therefore, it is important to have accurate information available from the internet to minimise unnecessary patient fear and anxiety.

 ¤ Materials and Methods Top

In September 2015, we searched the World Wide Web using the five most popular search engines (Google,[15] Bing,[16] Yahoo! Search,[17] Ask [18] and AOL Search [19]) with the keyword 'laparoscopic cholecystectomy'. We kept the default settings, and did not use any plug-ins or advanced search options. The LIDA tool was used to assess the first 50 web links in each of the five searches.


The websites should meet legal accessibility requirements, including W3C. The World Wide Web Consortium (W3C) is an international community working on developing Web standards. The information available should be without restrictions or outdated HTML codes. We assessed this aspect of accessibility by using an online tool designed for the LIDA tool.[7] The websites should open on all frequently used browsers and platforms (we assessed this using Windows operating system and three browsers: Google chrome, Internet Explorer and Firefox). The information should also be available in full text without registration, login or subscription. This is important because freely accessible websites have a higher impact than do sites with restricted access.[20] The highest possible score was 63.


To assess the usability of the websites, clarity of presentation, consistency of webpage design, functionality and engagability were assessed. The maximum possible score was 54.


Providing accurate and relevant information in an easily comprehensible manner should be an important aspect of a healthcare website targeting the public. Regular updates (currency), clear declaration of conflicts of interest, and rigorous methodology for content production and output gives some indications about the reliability of a website. Therefore, these criteria were assessed according to LIDA tool to evaluate the reliability of each website. The maximum possible score was 27 without supplementary questions, as assessing supplementary questions was practically difficult due to the necessity of contacting host organisations for completing a detailed examination of the website production process.

The LIDA scores were considered to be 'low' if they were below 50%, 'moderate' if they were 50-90% and 'high' if they were above 90%.[7]

In this study we used FRES and GFI as readability tests. Both readability tests were performed using an online readability testing website.[21]

 ¤ Results Top

The search using the keywords resulted in thousands of websites. Of them, the first 250 websites were evaluated (top 50 links from each search engine). There were considerable overlaps among the websites. Of those 250 web links, 160 links were repetitions, restricted-access sites or previously evaluated sites. Therefore, 90 web links were evaluated. All links were in English.


The average accessibility score was 52/63 [Figure 1]. The score was well distributed among the websites, with 13 websites having high accessibility scores of more than 57 (90%), while the others had moderate scores [Table 1]. All the websites worked on all the operating systems and the browsers using which the study was conducted. Eight websites required free registration for access, while five required payment for registration.
Figure 1: Box-and-whisker plot of analysed websites. Top and bottom borders of the box mark the 75th and 25th percentiles. The horizontal line inside the box indicates the median. The whiskers mark the 90th and 10th percentiles

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Table 1: Distribution of number of websites according to LIDA subset scores

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The average usability score was 39/54. Scores were well distributed amongst websites [Figure 1]. Most of the websites had moderate scores (88) and one website achieved a high score, while the remaining one achieved a low score [Table 1].


The average reliability score was 14/27 (range 1-22) [Figure 1]. Thirty-four websites had low scores.

The overall average LIDA score for the websites was 106.44 (74.05%). Therefore, most websites scored moderately well with the LIDA tool. Two websites had high scores (>90%) [Table 1].

Readability scores

The readability of a text can be defined as the ease with which it can be read and understood.[13] In this study we used the two most reliable readability tests, the FRES and the GFI. The average FRES was 41.07 [Figure 1]. The range of the score distribution was 4.3-86.4. The websites with good FRES were found to have higher usability scores. The average GFI was 11.52.

 ¤ Discussion Top

There is an abundance of information available on the internet. With the expansion of internet access around the world, evaluating the quality of available information becomes a dire necessity as some of this information may be incorrect, commercially motivated or biased.

Search engines are the commonest tools used by the general public to access information on the internet. When a topic is searched using a search engine, thousands of links usually appear as results in several pages. The natural tendency is to read the links that appear at the top of a search. However, the links appearing on the top do not necessarily lead to the best websites. In addition, these websites may be commercially motivated. Yet most general users do usually visit only the top links appearing for a search.

There are some websites that provide accurate information in an easily comprehensible form. However, their rankings on search results were variable.

In this study we evaluated the top 50 ranked web links on the five most popular search engines using the keyword 'laparoscopic cholecystectomy'. We used the top 50 links as those links had the highest likelihood of being accessed by the average user.[10]

To evaluate the quality of websites we used the LIDA tool. There are many tools available to evaluate the quality of websites but only a few have been tested for their reliability. LIDA is a validated tool for assessing the quality of healthcare websites and it also evaluates their accessibility, usability and reliability.[7] Therefore, we used the LIDA tool for this study.

FRES and GFI are validated tools for assessing the readability of English texts. Short sentences in simple words can give high FRES and high GFI scores but may be not be interesting to the reader. Therefore, these tests can be used only as an indicator of the readability level of a website. In addition, the readability scores can be variable when calculated manually or by using different software.

In this study, we used the five most popular search engines in their default settings. However, the default settings of each search engine may be different according to the country of origin. Further, if a plug-in is used, the settings determined on installation may be different.

Similar studies have been conducted in context of other surgical branches as well. Roshan et al.[8]conducted a study to assess information on the internet available to parents of children undergoing tonsillectomy. They assessed 113 websites and found an average accessibility of 66.7%, an average usability of 53.7% and an average reliability of 33.3%. Average FRES was 43.8. In contrast, our study showed accessibility, usability, reliability and FRES score of 82%, 72%, 51% and 41, respectively.

 ¤ Conclusion Top

In this study, most of the websites scored moderately for usability, accessibility and readability. However, most of the websites scored poorly on reliability criteria when compared to their usability and accessibility scores. It was also shown that even if the reliability score of a website is low, the site can accrue a relatively high total mark by the LIDA tool by scoring well in the accessibility and usability sections. Therefore, making improvements in the information available on the internet is necessary to aid patients to make informed decisions. Patients should be guided to be able to select reliable and accurate websites. It is the duty of health professionals to select websites containing high-quality information that is easily comprehensible. The internet is probably the easiest way to access a large amount of information in a short period of time. Therefore, we cannot ignore the impact of information available on the internet in making health-related decisions. The accessibility, usability, reliability and readability of medical information available over the internet should be improved to provide better health services to the public.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.

 ¤ References Top

Coeira E. The internet's challenge to health care provision. BMJ 1996;312: 3-4.  Back to cited text no. 1
Jadad AR. Promoting partnerships: Challenges for the internet age. BMJ 1999;319:761-4.  Back to cited text no. 2
Guidelines for medical and health information sites on the Internet. Principles governing the AMA websites. Available from: [Last accessed on 2015 Sep 01].  Back to cited text no. 3
Impicciatore P, Pandolfini C, Casells N, Bonati M. Reliability of health information for the public on the world wide web: A systematic survey of advice on managing fever in children at home. BMJ1997;314: 1875-9.  Back to cited text no. 4
Eysenbach G, Diepgen TL. Towards quality management of medical information on the internet: Evaluation, labelling, and filtering of information. BMJ1998;317:1496-500.  Back to cited text no. 5
Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuringthe quality of medical information on the internet: Caveant lector et viewor — Letthe reader and viewer beware. JAMA1997;277:1244-5.  Back to cited text no. 6
LIDA M. Validation instrument for healthcare Websites. Available from: [Last accessed on 2015 Sep 01].   Back to cited text no. 7
Roshan A, Agarwal S, England RJ. Role of information available over the internet: What are the parents of children undergoing tonsillectomy likely to find? Ann R Coll Surg Engl 2008;90:601-5.  Back to cited text no. 8
Quantcast – Top Ranking International Websites [Internet]. 2015. Available from: [Last accessed on 2015 Sep 01].  Back to cited text no. 9
Eysenbach G, Köhler C. How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests and in-depth interviews. BMJ 2002;324:573-7.  Back to cited text no. 10
Wyatt JC. Commentary: Measuring quality and impact of the World Wide Web.BMJ 1997;314:1879-81.  Back to cited text no. 11
Wikipedia. Flesch–Kincaid Readability Test. Available from: [Last accessed on 2015 Sep 01].   Back to cited text no. 12
Grewal P, Williams B, Alagaratnam S, Neffendorf J, Soobrah R. Quality of vascular surgery Web sites on the Internet. J Vasc Surg 2012;56:1461-7.   Back to cited text no. 13
Duca S, Bãlã O, Al-Hajjar N, Lancu C, Puia IC, Munteanu D, et al. Laparoscopic cholecystectomy: Incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations. HPB 2003;5:152-8.  Back to cited text no. 14
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Murali NS, Murali HR, Auethavekiat P, Erwin PJ, Mandrekar JN, Manek NJ, et al. Impact of FUTON and NAA bias on visibility of research. Mayo Clin Proc 2004;79:1001-6.  Back to cited text no. 20
Measure the Readability of Web Pages! - Improve your writing and your website marketing with [Internet]. 2015. Available from: [Last accessed on 2015 Sep 01].  Back to cited text no. 21


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  [Table 1]

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