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ENHANCING SAFETY IN LAPAROSCOPIC CHOLECYSTECTOMY: INSIGHTS FROM A PROSPECTIVE STUDY ON CRITICAL VIEW OF SAFETY AND CASE FOR EARLY ADOPTION
Lovenish Bains
*, Aman Agarwal, Pawan Lal, Uday Kumar
Surgery, Maulana Azad Medical College, New Delhi, Delhi, India
BACKGROUNDLaparoscopic cholecystectomy is considered the gold standard for treating gallstones, with the critical view of safety (CVS) being a crucial technique. Achieving CVS is vital for minimizing the risk of bile duct injuries, which now occur in 0.4-1.8% of cases, a notable decrease from previous rate of 1-2.2% before the widespread adoption of CVS.
METHODThis prospective observational study, conducted over one year, assessed the achievement of the critical view of safety (CVS) and complication rates during laparoscopic cholecystectomy across various levels of surgical experience. We included patients aged 18-60, with each procedure recorded and reviewed by experienced surgeons. The study outcomes were attainment of CVS, time required to achieve it, and the complication rates for both residents and consultants. Case difficulty was classified using Nassar’s criteria.
RESULTA total of 225 cases were included in the study, categorized by Nassar’s grading system: Grade I (n=160), II (n=33), III (n=18), and IV (n=14). Among the Grade III cases, 40% (n=18) did not achieve the CVS, and 62% of Grade IV cases (n=14) lacked a defined CVS. In these cases, bailout procedures were necessary, including subtotal cholecystectomy (n=5), conversion to open cholecystectomy (n=2), and a retrograde approach (n=7). Consultants (n=124) achieved CVS in 92.6% of cases overall. CVS was achieved in 100% of Grade I and II cases, but in only 56% of Grade III and 40% of Grade IV cases. Registrars (n=101), on the other hand, achieved CVS in 74% of cases overall, with success rates of 91% for Grade I, 72% for Grade II, 42% for Grade III, and none in Grade IV. The average time to achieve CVS varied according to Nassar's grading system. Complications were classified according to the Clavien-Dindo system: Grade I (n=30), II (n=14), III (n=4), IV (n=3), including bowel injury & bile duct injury (BDI). There were no BDI among consultants, but three cases of BDI (two cystic duct stump leaks and one requiring hepaticojejunostomy) occurred among registrars.
DISCUSSIONThe critical view of safety in laparoscopic cholecystectomy is key to reducing bile duct injuries. By improving the visualization of cystic structures, this technique has helped lower injury rates from 0.5-0.8% to below 0.3% with widespread adoption. Our study shows that consultants take about 24 minutes to achieve CVS across Nassar’s Grade I-III, while registrars take around 38 minutes for Grade I-II, with BDI rates of 0% and 2.97%, respectively. Despite being established for over 20 years, global adoption of CVS remains low. Our study, along with other studies, highlights that CVS significantly reduces the risk of bile duct injuries (BDI). Given its proven benefits, CVS should be adopted as a standard practice worldwide to enhance patient safety & improve outcomes in laparoscopic cholecystectomy.
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