Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors o
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and Other Interventional Techniques
Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure Ahmad H. M. Nassar1 · Hwei J. Ng2 · Arkadiusz Peter Wysocki3 · Khurram Shahzad Khan2 · Ines C. Gil4 Received: 27 June 2020 / Accepted: 3 October 2020 © The Author(s) 2020
Abstract Background Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The “culture of safety” concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies. Aims and methods A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely. Results The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions. Conclusion All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered. Keywords Laparoscopic cholecystectomy · Salvage cholecystectomy · Critical view of safety · Difficulty grading · Nassar difficulty scale · Bile duct injury · Cholecystectomy complications · Subtotal cholecystectomy · Fundus first dissection The incidence of major bile duct injury (BDI) during laparoscopic cholecystectomy (LC) has remained relatively constant ranging from 0.1% to 1.5% [1, 2] despite improvements in equipment and techniques, while the incidence during open cholecystectomy is typically quoted as 0.2% [3]. Avoiding bile duct injury is important as this results
* Ahmad H. M. Nassar [email protected]; [email protected] 1
University Hospital Monklands, Airdrie, Lanarkshire ML6 0JSb, Scotland
2
NHS Greater Glasgow and Clyde, Glasgow, UK
3
Logan Hospital, Corner Meadowbrook and Loganlea Roads, Meadowbrook, Logan City, QLD 4133, Australia
4
Centro Hospitalar de Leiria, Leiria, Portugal
in additional morbidity, mortality and escalation of health care costs
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