Adam Niemann, Niki Matsuko, Gurjit Sandhu, PhD, Oliver Varban, MD. University of Michigan
Background: Despite well-established criteria for identifying the critical view of safety (CVS) during laparoscopic cholecystectomy, its direct effect on safe intra-operative decision-making is unclear.
Objective: Using surgical video review, our goal was to assess how likely participants would commit to dividing critical structures at various points of dissection when using the CVS criteria.
Methods: General surgery interns (n=10) at a single-center academic institution viewed a training module on the components of the CVS criteria and then independently reviewed 20 laparoscopic/robotic cholecystectomy videos lasting 1 minute each. Videos were edited at various points of CVS dissection of the CVS to include examples of both adequate and inadequate dissections. Participants were asked to identify the following components of the CVS criteria in the video: 1) Hepatocystic triangle cleared of fat and fibrous tissue; 2) Clearance of the lower 1/3rd of the cystic plate; 3) Two structures entering the gallbladder and 4) Doublet view was obtained; and decide if they thought the structures were safe to divide. Cohen’s kappa statistic was used to evaluate inter-rater agreement for each component of the CVS criteria.
Results: Inter-rater agreement among the components of the CVS criteria varied: Component 1 – k=0.2510, Component 2 – k=0.2771, Component 3 – k=0.4298 and Component 4 – k=0.4398. Participants chose to divide critical structures in all instances when all 4 components of the CVS were identified and decided to avoid division of structures in all instances when none of the components of the CVS were identified. Among cases in which only 1-3 components were identified, there was a higher likelihood of dividing critical structures when 3 criteria were met vs. 1 criteria (OR 6.95, p=0.017). Among cases in which critical structures were divided and only 1-3 components of the criteria were satisfied (28.8%), participants were most likely to omit the doublet view (57.1%).
Conclusions: When reviewing videos of laparoscopic cholecystectomy at various points of dissection, participants were least likely to agree upon what constituted an adequate hepatocystic dissection or clearance of the lower 1/3rd of the cystic plate. Participants were also most likely to omit the doublet view criteria when dividing critical structures. Video-based assessments that include intraoperative decision-making can help identify variations in perceptions of anatomy as well as gaps in safe practices.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87764
Program Number: S083
Presentation Session: MIS Education Session
Presentation Type: Podium