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. 2021 Nov;35(11):6039-6047.
doi: 10.1007/s00464-020-08093-3. Epub 2020 Oct 16.

Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure

Ahmad H M Nassar  1 , Hwei J Ng  2 , Arkadiusz Peter Wysocki  3 , Khurram Shahzad Khan  2 , Ines C Gil  4
Affiliations

Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure

Ahmad H M Nassar et al. Surg Endosc. 2021 Nov.

Abstract

Background: Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies.

Aims and methods: A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely.

Results: The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions.

Conclusion: All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered.

Keywords: Bile duct injury; Cholecystectomy complications; Critical view of safety; Difficulty grading; Fundus first dissection; Laparoscopic cholecystectomy; Nassar difficulty scale; Salvage cholecystectomy; Subtotal cholecystectomy.

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Conflict of interest statement

Drs AHM Nassar, HJ Ng, AP Wysocki, KS Khan and IC Gil have no conflict of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Subserosal dissection of an inflamed, thick-walled gallbladder
Fig. 2
Fig. 2
Contracted gallbladder withdrawing a dilated bile duct laterally. CVS was impossible
Fig. 3
Fig. 3
Transvesical cholangiography
Fig. 4
Fig. 4
Following limited funds first dissection, the "funnel" technique is used to access the posterior aspect of the Hartman's Pouch allowing the creation of a stump
Fig. 5
Fig. 5
Safety pathway, time-out and salvage strategies for laparoscopic cholecystectomies where failure of CVS is predicted
See this image and copyright information in PMC

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