Rationale and Use of the Critical View of Safety in Laparoscopic Cholecystectomy

Abstract

The introduction of laparoscopic cholecystectomy was associated with a sharp rise in the incidence of biliary injuries. ¹ A prospective analysis of 1518 laparoscopic cholecystectomies The Southern Surgeons Club. N Engl J Med. 1991; 324 : 1073-1078 Crossref PubMed Scopus (1332) Google Scholar Despite the advancement of laparoscopic cholecystectomy techniques, biliary injury continues to be an important problem today, although its true incidence is unknown. The most common cause of serious biliary injury is misidentification. Usually, the common bile duct is mistaken to be the cystic duct and, less commonly, an aberrant duct is misidentified as the cystic duct. ² Strasberg S.M. Hertl M. Soper N.J. An analysis of the problem of biliary injury during laparoscopic cholecystectomy [see comments]. J Am Coll Surg. 1995; 180 : 101-125 PubMed Google Scholar The former was referred to as the “classical injury” by Davidoff and colleagues, who described the usual pattern of evolution of the injury at laparoscopic cholecystectomy. ³ Davidoff A.M. Pappas T.N. Murray E.A. et al. Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg. 1992; 215 : 196-202 Crossref PubMed Scopus (467) Google Scholar In 1995, we authored an analytical review of this subject and introduced a method of identification of the cystic structures referred to as the “critical view of safety” (CVS) ² Strasberg S.M. Hertl M. Soper N.J. An analysis of the problem of biliary injury during laparoscopic cholecystectomy [see comments]. J Am Coll Surg. 1995; 180 : 101-125 PubMed Google Scholar ( Fig. 1). (This approach to ductal identification had been described in 1992, ⁴ Strasberg S.M. Sanabria J.R. Clavien P.A. Complications of laparoscopic cholecystectomy. Can J Surg. 1992; 35 : 275-280 PubMed Google Scholar but the term critical view of safety was used first in our 1995 article.) During the past 15 years, this method has been adopted increasingly by surgeons around the world for performance of laparoscopic cholecystectomy. ⁵ Avgerinos C. Kelgiorgi D. Touloumis Z. et al. One thousand laparoscopic cholecystectomies in a single surgical unit using the “critical view of safety” technique. J Gastrointest Surg. 2009; 13 : 498-503 Crossref PubMed Scopus (98) Google Scholar ^{,  6} Heistermann H.P. Tobusch A. Palmes D. [Prevention of bile duct injuries after laparoscopic cholecystectomy. “The critical view of safety”]. Zentralblatt fur Chirurgie. 2006; 131 : 460-465 Crossref PubMed Scopus (22) Google Scholar ^{,  7} Yegiyants S. Collins J.C. Yegiyants S. Collins J.C. Operative strategy can reduce the incidence of major bile duct injury in laparoscopic cholecystectomy. Am Surg. 2008; 74 ( 985-957) Google Scholar ^{,  8} Auyang E.D. Hungness E.S. Vaziri K. et al. Natural orifice translumenal endoscopic surgery (NOTES): dissection for the critical view of safety during transcolonic cholecystectomy. Surg Endosc. 2009; 23 : 1117-1118 Crossref PubMed Scopus (22) Google Scholar When the method was initially described, it was done so with a brief description and picture, without a thorough explanation of the rationale for this approach. ² Strasberg S.M. Hertl M. Soper N.J. An analysis of the problem of biliary injury during laparoscopic cholecystectomy [see comments]. J Am Coll Surg. 1995; 180 : 101-125 PubMed Google Scholar The primary purpose of this short communication is to present that rationale so that surgeons can better apply CVS by understanding why the method is protective against misidentification. A second purpose is to review the current status of the use of CVS and to suggest approaches that might reduce the incidence of biliary injury through its use. Figure 1 The critical view of safety. The triangle of Calot has been dissected free of fat and fibrous tissue, however, the common bile duct has not been displayed. The base of the gallbladder has been dissected off the cystic plate and the cystic plate can be clearly seen. Two and only 2 structures enter the gallbladder and these can be seen circumferentially. View Large Image Figure Viewer Download Hi-res image