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Critical View of Safety in Laparoscopic Cholecystectomy: A Systematic Review of Current Evidence and Future Perspectives

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Abstract

Background

The Critical View of Safety (CVS) has been increasingly recognised as the standard method for identification of the cystic structures, to prevent vasculobiliary injuries during laparoscopic cholecystectomy, however, its adoption has been anything but universal. A significant proportion of surgeons has a poor understanding of the three requirements. To bridge this gap between theory and practice, we aimed to summarise the available evidence on CVS, emphasising on current debates and future perspectives.

Method

We systematically reviewed the literature (1995–2021), to identify studies reporting on the CVS. Eligible articles were classified according to methodology and key idea. A quantitative analysis was performed to evaluate effectiveness of the CVS in preventing bile duct injury (BDI).

Results

150 relevant articles were identified, focusing on six main points, (1) safety and effectiveness, (2) intraoperative documentation, (3) complementary imaging techniques, (4) bail-out alternatives, (5) adoption among surgeons, and (6) education and training. The quantitative analysis included 11 studies, with 10,938 cases. Overall, the CVS was achieved in 92.5%. Conversion rate was 4.8%. CVS-related BDI was 0.09% (0.05% technical errors and 0.04% misidentification errors).

Conclusion

Routine application of the CVS reduces BDI, but does not eliminate them altogether. Besides operative notes, the CVS should be documented by an imaging modality of sufficient quality. When the CVS cannot be safely established, the threshold for bail-out alternatives or complementary imaging should be low. Adoption by the surgical community worldwide shows great variability and focus should be placed on training through structured educational modules.

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Authors and Affiliations

  1. Department of Surgery, Athens Naval and Veterans Hospital, Deinokratous 70, 11521, Athens, Greece

    Dimitrios K. Manatakis, Maria-Ioanna Antonopoulou, Nikolaos Tasis & Christos Agalianos

  2. Department of Surgical Oncology, St Savvas Cancer Hospital, Athens, Greece

    Dimitrios K. Manatakis & Dimitrios P. Korkolis

  3. Department of Surgery, Stony Brook University Hospital, Stony Brook, USA

    Ioannis Tsouknidas

  4. Department of Hepatobiliary and Pancreatic Surgery, Metropolitan Hospital, Piraeus, Greece

    Christos Dervenis

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  1. Dimitrios K. Manatakis
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  2. Maria-Ioanna Antonopoulou
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Correspondence to Dimitrios K. Manatakis.

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Drs Dimitrios K. Manatakis, Maria-Ioanna Antonopoulou, Nikolaos Tasis, Christos Agalianos, Ioannis Tsouknidas, Dimitrios P. Korkolis and Christos Dervenis have no conflicts of interest or financial ties to disclose.

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Manatakis, D.K., Antonopoulou, MI., Tasis, N. et al. Critical View of Safety in Laparoscopic Cholecystectomy: A Systematic Review of Current Evidence and Future Perspectives. World J Surg 47, 640–648 (2023). https://doi.org/10.1007/s00268-022-06842-0

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