Improving attainment of the critical view of safety during laparoscopic cholecystectomy



We hypothesized that practicing surgeons would successfully achieve a better and more frequent Critical View of Safety (CVS) during laparoscopic cholecystectomy (LC) after participation in a structured Safe CVS Curriculum.


All surgeons performing LC at a regional health system had four LC cases recorded: twice before and twice after a curriculum focused on the CVS, which was led by a member of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Safe LC Task Force. Videos were then de-identified and randomly ordered for grading on a 6-point CVS assessment tool by two expert surgeons, who were blinded to the operator and whether the surgeries were performed before or after the curriculum. Confidence surveys and performance on a CVS identification video quiz were also compared pre- and post-curriculum.


Twelve surgeons (five general, four acute care, and three minimally invasive) with an average experience of 17.9 ± 6.3 years participated in the study. After the curriculum, surgeons achieved all three CVS criteria in more cases (1/24 (4%) versus 10/24 (42%), p < 0.004). There was also significant improvement in correctly identifying whether the CVS was achieved in 10 video clips from the Internet (7.9 ± 1.5 vs. 9.3 ± 0.8, p = 0.006) and increased confidence on a 5-point Likert scale in accurately identifying the CVS (4.5 ± 0.5 vs. 4.9 ± 0.3, p = 0.017).


A structured curriculum on achieving a quality CVS for practicing, experienced surgeons improved their confidence and frequency of obtaining the Critical View of Safety during LC. We recommend that the Safe CVS Curriculum be considered for widespread use in order to increase the quality and frequency of attaining the Critical View of Safety.

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Correspondence to Michael Ujiki.

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Michael Ujiki is a consultant for Olympus, on the Boston Scientific scientific advisory board, a consultant and speaker for Apollo Medical Devices, a speaker for Medtronic, and a speaker for Gore Medical. Tetsuya Nakazato, Bailey Su, Stephanie Novak, Shanley B. Deal, and Kristine Kuchta have no conflicts of interest or financial ties to disclose

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Nakazato, T., Su, B., Novak, S. et al. Improving attainment of the critical view of safety during laparoscopic cholecystectomy. Surg Endosc 34, 4115–4123 (2020).

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  • Critical view of safety
  • Laparoscopic cholecystectomy
  • Surgical education
  • Structured curriculum
  • Bile duct injury