THE CRITICAL VIEW OF SAFETY PREVENTS THE APPEARANCE OF BILIARY INJURIES? ANALYSIS OF A SURVEY

CRITICAL VIEW OF SAFETY: A PROSPECTIVE SURGICAL AND PHOTOGRAPHIC ANALYSIS IN LAPAROSCOPIC CHOLECYSTECTOMY - DOES IT HELP TO PREVENT IATROGENIC LESIONS?

BACKGROUND

The incidence of biliary duct injuries remains higher in laparoscopic cholecystectomy (LC) in comparison to open surgery. The Critical View of Safety (CVS) was introduced by Strasberg as a strategy for reducing this catastrophic complication. AIM: The aim of this study was to evaluate how often an adequate CVS is achieved during LC, the determining factors for its success, and the associated surgical outcomes.

METHODS

This is a prospective study. CVS photographs of all patients who underwent LC by the same surgeon between 2020 and 2023 were taken. Success in achieving CVS was analyzed by the surgeon herself and posteriorly by hepatobiliary specialists. Patients were classified into two groups: CVS achieved and CVS not achieved. Finally, multivariable logistic regression was used to examine the association between preoperatory factors and surgical complications.

RESULTS

Three hundred and nine consecutive patients were submitted to LC. There were 73.5% elective CL and 26.5% acute cholecystitis. The age ranged from 14 to 87 years, and 76.8% were female. The median body mass index was 26.7. Previous abdominal surgeries were present in 64%, and 26% were obese. The CVS was achieved in 79.9% of the patients, and there were no surgical complications in this group. The factors associated with nonachievement were acute cholecystitis (p=0.007), male sex (p=0.014), and previous surgeries (p=0.021). Three patients needed a subtotal cholecystectomy due to severe inflammation. There was no statistical correlation between the identification of CVS and surgical complications.

CONCLUSIONS

The CVS is achieved in most patients. Acute cholecystitis, male sex, and previous abdominal operations are associated with difficulties in obtaining CVS.

Critical View of Safety in Laparoscopic Cholecystectomy: A Systematic Review of Current Evidence and Future Perspectives

BACKGROUND

The Critical View of Safety (CVS) has been increasingly recognised as the standard method for identification of the cystic structures, to prevent vasculobiliary injuries during laparoscopic cholecystectomy, however, its adoption has been anything but universal. A significant proportion of surgeons has a poor understanding of the three requirements. To bridge this gap between theory and practice, we aimed to summarise the available evidence on CVS, emphasising on current debates and future perspectives.

METHOD

We systematically reviewed the literature (1995-2021), to identify studies reporting on the CVS. Eligible articles were classified according to methodology and key idea. A quantitative analysis was performed to evaluate effectiveness of the CVS in preventing bile duct injury (BDI).

RESULTS

150 relevant articles were identified, focusing on six main points, (1) safety and effectiveness, (2) intraoperative documentation, (3) complementary imaging techniques, (4) bail-out alternatives, (5) adoption among surgeons, and (6) education and training. The quantitative analysis included 11 studies, with 10,938 cases. Overall, the CVS was achieved in 92.5%. Conversion rate was 4.8%. CVS-related BDI was 0.09% (0.05% technical errors and 0.04% misidentification errors).

CONCLUSION

Routine application of the CVS reduces BDI, but does not eliminate them altogether. Besides operative notes, the CVS should be documented by an imaging modality of sufficient quality. When the CVS cannot be safely established, the threshold for bail-out alternatives or complementary imaging should be low. Adoption by the surgical community worldwide shows great variability and focus should be placed on training through structured educational modules.

Evaluation of the knowledge of the critical view of safety and recognition of the transoperative complexity during the laparoscopic cholecystectomy

INTRODUCTION

Since the establishment of the Critical view of safety (CVS), different strategies have been created such as bailout procedures (SC, subtotal cholecystectomy), classifications for preoperative and intraoperative complexity (The Parkland grading scale, PGS) and objective evaluation of the CVS (doublet score, DS) to establish a "Culture of Safety in Cholecystectomy, COSIC"; to avoid complications.

METHODS

A multiple choice questionnaire was applied to residents and graduated surgeons from different Hospitals in Mexico during different national meetings; evaluating the knowledge of this different concepts (CVS, SC, PGS, DS), univariate logistic regression was used to assess the association of the knowledge with adverse events (AE) like the Bile duct injury.

RESULTS

A total of 744 questionnaires were evaluated; 284 (38.17%) women and 460 (61.83%) men; 436 (58.6%) were residents and 308 (41.4%) graduated surgeons. 708 (95.16%) reported knowing the CVS; however, only (51.98%, p ≤ 0.001) defined the concept correctly, while 136 (18.28%) reported knowing the DS, but only 44 (5.91%) defined it correctly. Regarding the PGS, 398 (53.49%) mentioned knowing it, but only 262 defined it correctly. The concept of SC 642 (86.29%) reported knowing it; however, only (56.7%, p ≤ 0.001) correctly defined the techniques, being the reconstituting technique the preferred one (42.37% vs 34.89%). In this survey, the correct knowledge of the CVS (OR 0.47, p < 0.001), the subtotal techniques (OR 0.71 p = 0.07), the DS (OR 0.48 p < 0.001) and of the PGS (OR 0.28, p < 0.001) decreased the risk of presenting BDI.

CONCLUSION

Despite the COSIC and the timing of publication of the CVS; the percentage of people who can correctly define basic safety concepts is low among residents and licensed surgeons. Therefore, it is important to emphasize the dissemination of these concepts to obtain safe LC and thus reduce the incidence of complications.

Critical view of safety in laparoscopic cholecystectomy: A prospective investigation from both cognitive and executive aspects

Background

The achievement rate of the critical view of safety during laparoscopic cholecystectomy is much lower than expected. This original study aims to investigate and analyze factors associated with a low critical view of safety achievement.

Materials and Methods

We prospectively collected laparoscopic cholecystectomy videos performed from September 2, 2021, to September 19, 2021, in Sichuan Province, China. The artificial intelligence system, SurgSmart, analyzed videos under the necessary corrections undergone by expert surgeons. Also, we distributed questionnaires to surgeons and analyzed them along with surgical videos simultaneously.

Results

We collected 169 laparoscopic cholecystectomy surgical videos undergone by 124 surgeons, among which 105 participants gave valid answers to the questionnaire. Excluding those who conducted the bail-out process directly, the overall critical view of safety achievement rates for non-inflammatory and inflammatory groups were 18.18% (18/99) and 9.84% (6/61), respectively. Although 80.95% (85/105) of the surgeons understood the basic concept of the critical view of safety, only 4.76% (5/105) of the respondents commanded all three criteria in an error-free way. Multivariate logistic regression results showed that an unconventional surgical workflow (OR:12.372, P &lt; 0.001), a misunderstanding of the 2nd (OR: 8.917, P &lt; 0.05) and 3rd (OR:8.206, P &lt; 0.05) criterion of the critical view of safety, and the don't mistake “fundus-first technique” as one criterion of the critical view of safety (OR:0.123, P &lt; 0.01) were associated with lower and higher achievements of the critical view of safety, respectively.

Conclusions

The execution and cognition of the critical view of safety are deficient, especially the latter one. Thus, increasing the critical view of safety surgical awareness may effectively improve its achievement rate.