European Radiology

, Volume 29, Issue 2, pp 674–681 | Cite as

Patient dose reference levels in surgery: a multicenter study

  • J. GreffierEmail author
  • C. Etard
  • O. Mares
  • F. Pereira
  • D. Defez
  • C. Duverger
  • P. Branchereau
  • J. P. Beregi
  • R. Coulomb
  • A. Larbi



To assess diagnostic reference levels (DRLs) in surgery for the most frequent procedures as required by the European Directive 2013/59/Euratom.


A survey was conducted in six centers. Eight orthopedic, urology and gastrointestinal surgical procedures were analyzed. Kerma area product (KAP) and fluoroscopy time (FT) were recorded for 50 patients (except for elbow: 30 patients) per procedure and per center from September 2016 to September 2017. DRLs were calculated as the 3rd quartiles of the distributions. For shoulder surgery, DRLs were defined according to the complexity of the procedure. For hand/wrist and foot/ankle surgery, DRLs were defined according to the technology (conventional C-arm vs. mini-C-arm).


Results of 1870 procedures were retrieved. DRLs were calculated for the two dosimetric indicators and the eight procedures. DRLs were 2130 mGy.cm2 and 1.4 min for proximal femoral intramedullary nail, 1185 mGy.cm2 and 0.9 min for laparoscopic cholecystectomy and 2195 mGy.cm2 and 1.0 min for double-J (pigtail) ureteral catheter insertion. For shoulder surgery, KAP and FT were significantly higher (p < 0.05) for intramedullary procedures compared to extramedullary procedures. For hand/wrist and foot/ankle surgery, the KAPs were significantly higher (p < 0.05) with conventional C-arm compared to mini-C-arm, but FTs were not significantly different (p: not significant).


This study reports DRLs in surgery based on a multicentric survey.

Key Points

• Delivered dose in surgery depends on procedure, practice and patient.

• Diagnostic reference levels (DRLs) are proposed for eight surgical procedures.

• DRLs are useful to benchmark practices and optimize protocols.


Surgery Radiation exposure Radiation protection Dosimetry Fluoroscopy 



Diagnostic reference level


Fluoroscopic time


Kerma area product


Dose management system



We would like to thank all radiation protection operators who took the time to collect and check the data, especially in private clinics. We thank Sarah Kabani for her help in editing the manuscript.


The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Jean Paul Beregi.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the institutional review board.

Ethical approval

Institutional review board approval was obtained.


• retrospective

• multicenter study

Supplementary material

330_2018_5600_MOESM1_ESM.docx (1.5 mb)
ESM 1 (DOCX 1554 kb)


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Copyright information

© European Society of Radiology 2018
corrected publication August/2018

Authors and Affiliations

  1. 1.Department of RadiologyNîmes University HospitalNîmes Cedex 9France
  2. 2.Institut de Radioprotection et de Sûreté NucléaireFontenay-aux-RosesFrance
  3. 3.Department of SurgeryNîmes University HospitalNîmes Cedex 9France
  4. 4.Service de Physique Médicale et RadioprotectionCentre Hospitalier Lyon SudPierre-BeniteFrance

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