How Often Do Surgeons Obtain the Critical View of Safety During Laparoscopic Cholecystectomy?

Bindhu Oommen, MD, MPH, Brittany L Anderson-Montoya, PhD, Manuel Pimental, BS, Dimitrios Stefanidis, MD, PhD. Carolinas Medical Center, Charlotte, NC


The reported incidence (0.4-0.5%) of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is higher than during open cholecystectomy and has not decreased over time despite increasing experience with the procedure. The “critical view of safety” (CVS) has been suggested as a protective method to avoid BDI when certain criteria are met prior to division of any structures. The purpose of this study was to evaluate the adherence of practicing surgeons to the CVS criteria during LC.


As part of an IRB approved quality improvement project, laparoscopic cholecystectomy procedures performed by a variety of attending and private general surgeons at four institutions were recorded. Participation was voluntary. De-identified videos were reviewed by a blinded observer and rated on a six-point scale using the previously published CVS criteria by Strasberg (≤4 score represents inadequate CVS). The CVS was assessed just before the first structure was divided during LC. Operative data (including duration and difficulty on a five-point scale), patient demographics, and postoperative outcomes to 90 days were recorded. Operative notes were reviewed to assess whether surgeons indicated that they had obtained the critical view.


The rater assessed ten laparoscopic cholecystectomy videos, each involving a different surgeon. Patient characteristics were as follows: mean age 46.7±16.4 years, mean BMI 31.3±8.7 kg/m2, 80% women, 70% Caucasian race, 80% ASA Class II. Five patients had private insurance, 2 public, 2 both, and 1 was self-pay. The majority of cases were elective (80%) and outpatient (80%). Mean procedure duration was 95.4±51.7 minutes, and the average difficulty of the case as reported by the surgeon was 2.4±1.5.

The critical view of safety was adequately achieved (score 6) by only 2 (20%) of the surgeons; both surgeons dictated in their operative report that they obtained the CVS. The remaining eight surgeons did not obtain adequate CVS prior to division of any structures (score ≤4); the mean score of this group was 1.75 while two surgeons received a score of 0. One in four surgeons with scores ≤4 dictated that they had obtained the critical view. There were no significant postoperative complications in any of the observed cases.


Widely accepted safety standards for the reduction of BDI during LC such as obtaining the CVS was not routinely used by the majority of general surgeons in our experience. Further, one-fourth of those who thought they obtained the CVS did so inadequately. Our findings suggest that education of practicing surgeons in the application of the CVS during LC is needed. If further evidence corroborates our findings it may explain, at least in part, the lack of improvement in BDI incidence despite increased experience with the procedure. Our study also supports the value of direct observation of surgical practices for quality improvement.

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