L. Traub1, C. Chen1, F. Palazzo1, E. Rosato1, H. Lavu1, J. Winter1, C. J. Yeo1, M. J. Pucci1 1Thomas Jefferson University,Surgery,Philadelphia, PA, USA
Introduction: Over 700,000 laparoscopic cholecystectomies (LC) are performed annually in the United States; and, while widely considered a safe operation, over 2000 bile duct injuries (BDI) occur. The critical view of safety (CVS) is a method of secure ductal identification to prevent BDI. Although, widely publicized, it remains unclear if surgeons understand its criteria, or may instead mistake the CVS for the “infundibular” approach, where BDI is possible.
Methods: Fifty-one LC were recorded via video and scored on a 6-point scale consisting of scores from 0 to 2 for each of the three criteria of the CVS. The operative notes were reviewed. A survey was sent to surgical faculty who routinely performed LC during the study period, asking them to label various commonly performed maneuvers as: potentially harmful, not necessary, preferred but not necessary, or safe and mandatory.
Results: Thirty-seven (73%) of the 51 operative notes reviewed documented CVS achievement. Only 8 (16%) cases scored > 4 (considered adequate) when reviewed on CVS assessment. Of the three criteria, “exposure of the cystic plate” scored lowest, with a mean of only 0.3. Twelve surgeons responded to the survey with 83% indicating visualization of only 2 structures entering the gallbladder is mandatory, 42% indicating that clearance of the hepatocystic triangle is mandatory, and only 25% responding exposure of the cystic plate was mandatory. However, 92% of respondents believe the “infundibular” approach is safe.
Conclusion: While experienced surgeons routinely mention the CVS in operative notes, these data suggest a misunderstanding of the three criteria, with a tendency towards the infundibular approach. Greater education is necessary, as the infundibular approach may result in BDI.
