Improving reaching critical view of safety in laparoscopic cholecystectomy with teaching interventions

Maj Nijssen, MD, JMJ Schreinemakers, MD, PhD, GP van der Schelling, MD, RMPH Crolla, MD, AM Rijken, MD, PhD. Department of Surgery, Amphia Hospital, Breda.


To prevent serious bile duct injuries in laparoscopic cholecystectomy, guidelines recommend that a critical view of safety (CVS) should be obtained in laparoscopic cholecystectomies. In a previous study we noticed that in cases with complications, CVS was not reached frequently. In an effort to improve these results, we gave a lecture for all surgeons and residents and send everyone an update on CVS along with a teaching video on how to perform a laparoscopic cholecystectomy and pitfalls. After nine months we repeated this educational intervention.



Of 257 consecutive patients we reviewed 178 available videos of laparoscopic cholecystectomies. Videos before and after the teaching interventions were reviewed by a senior surgical resident and a GI surgeon on whether CVS was reached or not (360° view on cystic duct, two window view between cystic duct and cystic artery and freeing of 1/3rd of the gallbladder from the liver). We prospectively collected demographic data, data of the procedure and complications.



Most patients underwent laparoscopic cholecystectomy for symptomatic cholecystolithiasis. The mean age was fifty-two years. In 69% of the pre-intervention patients (n=54) CVS was reached compared to 74% after the first teaching intervention (n=77) and 81% after the second intervention (n=50) (n.s.). The complication rate was 24% (n=18) before, 19% (n=25) after the first teaching intervention and 14% (n=7) after the second intervention (n.s.). In these groups, respectively two, three and one cases with biliary injury occurred. In all six cases it concerned a type A biliary injury.



By giving lectures and providing teaching information and videos to surgeons CVS was reached more frequently. Even though there was no significant improvement we believe that to improve the complication rate, especially major bile duct injuries, after laparoscopic cholecystectomies a teaching intervention is useful. Although it was not significant, CVS was reached more often after the teaching interventions (81% vs. 69%). Furthermore, less complications were observed.

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