The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study

Abstract

Background Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3-0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial. Methods Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor. Results Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding. Conclusions The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures. Keywords Cholecystectomy • Critical view of safety • Laparoscopy • Bile duct injuries • Intraoperative bleeding • Laparoscopic training Laparoscopic cholecystectomy (LC) is currently and worldwide considered the gold standard for the treatment of gallbladder lithiasis. Since its introduction, in the early 1990s, this procedure has gained a remarkable consensus until becoming a routine surgical procedure. LC is characterized by a reduction in postoperative pain, hospital stay, and recovery times to normal daily activities, which translates into reduced costs for the national healthcare systems (NHS) [1]. However, this procedure comes with an increased incidence of bile duct injuries (BDI), compared to open cholecystectomy (OC): 0.3% and 0.8% vs 0.2% [2-7]. LC-related BDIs include minor injuries up to complex hilar injuries, as classified by Strasberg et al., in which the and Other Interventional Techniques

Clinical and surgical algorithm for managing iatrogenic bile duct injuries during laparoscopic cholecystectomy: A multicenter study

“…It is obvious that there is still much effort to be put into significantly lowering this threshold ( 15 , 16 ). One way towards reaching this goal should be that all surgeons strictly adhere to the basic concept of always obtaining the critical view of safety advocated by Strasberg ( 17 ) and outlined by many studies published over the years ( 18 , 19 ).…”

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

“…The critical view of safety (CVS) technique was introduced in 1995 to guarantee the safest approach to LC by promoting the recognition of gallbladder elements, particularly the hepatocystic triangle (composed of the cystic duct, common bile duct, and liver) [40,41], a crucial step to reduce the risk of BDI associated with mistakes in visual perception. The literature has demonstrated that when the CVS is identified, the risk of iatrogenic intraoperative complications is minimized [42][43][44]. Thus, routine use of CVS is recommended over other techniques, such as the infundibular approach [5,42,45,46].…”

“…The literature has demonstrated that when the CVS is identified, the risk of iatrogenic intraoperative complications is minimized [42][43][44]. Thus, routine use of CVS is recommended over other techniques, such as the infundibular approach [5,42,45,46]. However, achieving a complete CVS is easily obtained in only 50% of cases.…”

Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements

“…Although some societies (Society of American Gastrointestinal and Endoscopic Surgeons-SAGES) performed campaigns to raise awareness among surgeons to use this philosophy in the "Safe Cholecystectomy Program" in order to minimize the risk of BDI (https://www.sages.org/safe-cholecystectomy-program/, accessed on 5 June 2021), there is still a low adoption of these suggestions [46], and the surgeons that non-use of CVS have a higher incidence of BDI (54.6%) than use CVS (25.8%) [67].…”