Achievement of Critical View of Safety and Preoperative Characteristics: A Step Toward Acknowledging the Inflection Point

Abstract

INTRODUCTION: The critical view of safety (CVS) is a surgical strategy that helps prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC). Bail-out procedure is indicated when the CVS cannot be achieved. The decision to halt the attempt of total cholecystectomy is termed inflection point. Few studies have analyzed operative difficulty as the ability to obtain the CVS, its relation to preoperative characteristics and postoperative complication. METHODS: Retrospective review of 119 patients who underwent emergency LC from March 2020 to July 2021. Patients with previous upper abdominal operation and hepatic disease were excluded. All LCs were performed by attendings. CVS was considered achieved by a 2-step review, including operative dictation and surgical video. A univariate analysis was conducted comparing the 2 groups. RESULTS: We found failure to obtain CVS in 42% of the cases; this was associated with male sex, odds ratio (OR) 2.38 (95% CI 1.13 to 5.03), BMI >35 kg/m2, OR 4.58 (95% CI 1.36 to 15.39), and a moderate/severe grade of cholecystitis OR 9.11 (95% CI 3.78 to 21.92). These patients had longer length of stay (LOS) 3.38 vs 1.68 days (p < 0.001) and higher incidence of complication, 10% vs 0% (p = 0.001), including major BDI and death (Table ). Table. - Results of the Univariate Analysis of Preoperative Characteristics for Achievement of Critical View of Safety Preoperative characteristic Failure to achieve CVS (n = 50) CVS achieved(n = 69) Odds ratio (95% CI) p Value Male sex 56% (28) 35% (24) 2.38(1.13–5.03) 0.02 Age >60 26% (13) 16% (11) 1.85(0.75–4.57) 0.18 BMI >35 kg/m2 22% (11) 6% (4) 4.58(1.36–15.39) 0.01 Moderate/severe AC (Grade II/III TG18) 82% (41) 33% (23) 9.11(3.78–21.92) <0.0001 WBC count (×103/μL) 9.59 (SD 3.37) 9.2 (SD 4.24) — 0.58 CONCLUSION: An association was found between preoperative values (male sex, BMI >35 kg/m2, and grade II/III acute cholecystitis) and failure to achieve CVS These preoperative clues may allow us to readily acknowledge the inflection point during emergency laparoscopic cholecystectomy to perform the safest surgical method. Our findings also support the association between failure of achieving CVS, increased LOS, and complication.