Critical view of safety (cvs) in laparoscopic cholecystectomy; what if you fail to establish?

Abstract

Background: Concept of establishing Critical View of Safety is currently recommended in Laparoscopic Cholecystectomy (LC) to minimize iatrogenic bile duct injuries. Methods: A prospective analysis was done on 72 consecutive LCs from April 2016 to January 2017 in a surgical unit at National Hospital of Sri Lanka. The hepatocystic triangle was dissected to establish CVS. Photo documentation of CVS was done prior to division of cystic duct and artery in each case. Retrograde dissection was performed when establishing CVS was difficult. Results: Out of 72 cases 53(73.6%) were females. Mean age was 48(range: 21-79) years. CVS was established in 55(76.3%) cases which included 3 empyemas, 5 mucocoeles, 3 acute cholecystitis and 14 chronic cholecystitis. Mean time for establishing CVS was 35.9(±16.2) minutes. Fibrosis and adhesions in hepatocystic triangle (64.7%) and doubtful anatomy (17.6%) were the commonest reasons for not establishing CVS. Three underwent subtotal cholecystectomy including one case of Mirizzi syndrome. Bile spillage (19.4%) & gallstone spillage (9.7%) were the commonest complications. Majority (92.1%) were discharged within 48 hours. None had bile duct injuries. Conversion and Mortality rates were zero. Conclusion: Establishing CVS is recommended as the starting point of dissection in LC. However if CVS is not established timely decision on retrograde dissection with appreciation of variable biliary anatomy will minimize the risk of iatrogenic bile duct injuries as well as conversion to open procedure.