Major iatrogenic bile duct injury during elective cholecystectomy: a Czech population register-based study

Laparoscopic cholecystectomy was introduced into wide practice about 1990, with demonstrated benefit to patients. However, it was associated with a sharp increase in major bile duct injuries. Biliary injuries are morbid, costly, and the source of litigation. Although not usually due to negligence, they are iatrogenic and detract from the value of laparoscopic cholecystectomy. Most major bile duct injuries are due to misidentification. In the “classical injury,” the common bile duct is thought to be the cystic duct and is divided. Aberrant hepatic ducts may also be mistakenly identified as the cystic duct or cystic artery. The Critical View of Safety (CVS) is a method of target identification, the targets being the cystic duct and the cystic artery. Today, CVS is taught and used widely. It is accepted as a good means of identification of the cystic structures and its use is within the standard of care. The purpose of this surgical perspective is to examine whether CVS has reached the status of being the only acceptable method for identification of structures in laparoscopic cholecystectomy. HISTORY OF THE CRITICAL VIEW OF SAFETY The term “Critical View of Safety” was introduced in an analytical review written in response to the sudden increase in biliary injury associated with laparoscopic cholecystectomy.1 CVS is a re-working of a method of secure identification in open cholecystectomy in which the cystic duct and artery are putatively identified, after which the gallbladder is taken off the cystic plate so that the gallbladder is attached only by the 2 cystic structures.2 Only then is secure target identification achieved. In laparoscopic surgery, complete separation of the gallbladder from the cystic plate makes clipping of the cystic structures difficult, so this step was modified to require only that the lower part of the gallbladder (about one-third) be separated from the cystic plate. The other requirements, that is, that the hepatocystic triangle be cleared of fat and fibrous tissue and that 2 and only 2 structures remain attached to the gallbladder, are the same as in the open technique. Intraoperatively, CVS should be confirmed in a “time-out” in which the 3 elements of CVS are demonstrated. After the introduction of CVS in1995, operative notes were studied in an attempt to determine if CVS was used in procedures in which biliary injury had occurred.3 It was found that the method of target identification that was failing was not CVS, but the infundibular technique in which the cystic duct is identified by exposing the funnel shape where the infundibulum of the gallbladder joins the cystic duct. Inflammatory fusion and contraction may cause juxtaposition or adherence of the common hepatic duct to the side of the gallbladder. When the infundibular technique of identification is used under these circumstances, a compelling visual deception may result that the common bile duct is the cystic duct.3 CVS is less susceptible to this deception because more exposure of structures is needed to achieve CVS. Either the CVS is attained, by which time the anatomic situation is usually clarified, or operative conditions such as severe acute or chronic inflammation prevent attainment of the CVS. In the latter case, when the CVS cannot be reached, 1 of several important “bail-out” strategies such as subtotal fenestrating cholecystectomy4 can be employed, thus avoiding bile duct injury. Of course, the CVS should not be seen in isolation, but as an element of an overall schema of a “Culture of Safety in Cholecystectomy” in which other elements such as good bail-out techniques, good access techniques, and other elements of safety are also employed. EFFECTIVENESS OF THE CRITICAL VIEW OF SAFETY There are 2 principal lines of evidence that the CVS is an effective method of target identification. First, there are several reports containing several thousand patients in which CVS was used for target identification without a biliary injury due to misidentification,5,6 whereas, based on an incidence of biliary injury of 3 to 4/1000 cases, about 20 biliary injuries would be expected. Secondly, in studies that have examined the mechanisms of major biliary injury, CVS has rarely been described as the method of target identification.7,8 Taken as a group, these studies are highly supportive of the value of CVS, but from the perspective of evidence-based medicine, they are at a low level of evidence. So, why after 25 years has there not been a randomized trial that compares methods of target identification? The answer lies in the fact that although many major biliary injuries still occur, that is, 2000 to 3000 per year in the USA, the event rate is only about 3 per 1000 cholecystectomies (up from about 1 per 1000 in the era of open cholecystectomy). A randomized trial cannot practically be performed because the event rate is so low that about 4500 patients per arm would be required. Despite the low event rate, biliary injuries are not uncommon because of the huge number of cholecystectomies performed annually—about 800,000 in the USA. Thus, biliary injury has aspects of a rare disease and a common disease. There are also important corollaries. Case series of laparoscopic cholecystectomies are almost always too small to provide insights into the causes of biliary injury. Population studies of thousands of patients are required to have enough events to gain meaningful insights. That is why going back almost 100 years,9 much of what is known about biliary injury has been gleaned not from case series of cholecystectomies, but from case series of the injuries themselves. WHAT CONSTITUTES STANDARD OF CARE? “Standard of care” is the legal term for the duty owed by one person to another and applies to both nonmedical and medical situations (such as driving a car). It is the amount of care that a reasonable person would take to prevent injury to another person. In the medical-legal context, a doctor must use the amount of skill, learning, and care ordinarily used by members of his/her profession in similar circumstances. Whether a given treatment or procedure is acceptably within the standard of care depends on whether it falls within the norms of practice, which are established by professional authorities in writings and recorded electronic communications. In recent years, the evidence presented in these communications has been graded from 1 to 5, with randomized trials being at a very high level, whereas case series and expert opinion are considered weaker evidences. Often several ways of diagnosis or treatment fall within the standard of care. Consensus conferences which weigh the available evidence regarding a type of care may sometimes conclude that there is high level evidence that one particular type of care is superior to all others. That type of conclusion, if based on high levels of evidence, could establish that failure to use a specific type of care in a particular situation will most likely be below the standard. An obvious example would be the failure to use antibiotics in an acute bacterial infection such as cellulitis. Finally, in determining standard of care, an important criterion is whether a type of care is in broad use by qualified surgeons. If it is, even by a moderate percentage of surgeons, then there is a strong argument that it falls within the standard of care. IS THE CRITICAL VIEW OF SAFETY THE ONLY ACCEPTABLE MEANS OF DUCTAL IDENTIFICATION DURING LAPAROSCOPIC CHOLECYSTECTOMY? Critical View of Safety, routine cholangiography, the infundibular technique, visualization of the common bile duct and common hepatic duct, and top-down cholecystectomy are some methods that have been advocated for target identification in cholecystectomy. CVS is not the only method within the standard of care for the following reasons. Textbooks of surgery may10 or may not11 recommend CVS as the method of target identification. The evidence that CVS is superior to all other methods is level 4, that is, case series. No consensus conference has published a guideline that CVS is the only effective method of target identification. Many surgeons in current practice use and are confident in other methods.12 The fact that some experts believe that CVS is the preferred method of target identification in laparoscopic cholecystectomy is insufficient alone to establish it as the only method within the standard of care. Stated otherwise, at this time, CVS is not the only method of ductal identification within the standard of care. PROBLEMS WITH CVS Dissemination of new information is a difficult problem in surgery. Even after more than 20 years, surgeons often have a poor understanding of the criteria for CVS, and may confuse CVS with the infundibular technique.12,13 Reluctance to adopt new techniques or methods can also be a challenge. In the case of CVS, this is compounded by the low event rate of biliary injury, which makes an error trap like the infundibular technique even harder to overcome. If it fails only 1 in 300 times, then it works 299 out of 300 times and there is a huge reservoir of confidence in it.13 Also, the infundibular method is easier and takes less dissection than CVS. Attainment of the CVS is not usually recorded or documented photographically, and although the dictated operative note may state that the CVS was achieved, recent evidence suggests this is frequently not the case.7 FUTURE OF CVS Critical View of Safety is part of the Culture of Safety In Cholecystectomy (COSIC) and this problem has been taken up by SAGES in a novel effort called “Safe Cholecystectomy” (www.sages.org/safe-cholecystectomy-program) The SAGES Safe Cholecystectomy program aims to better disseminate understanding and use of CVS and other strategies for prevention of biliary injury such as use of intraoperative imaging and approaches to the difficult gallbladder that include proper bail-out techniques.4 A multisociety consensus development conference is planned in 2017 on the subject of bile duct injury to study and promote safety in cholecystectomy. The role and application of CVS and other strategies for prevention of biliary injury will be critically examined in that forum. An effective and easy method of photodocumentation of CVS is now available for surgeons who wish to record CVS visually.14 For those who wish to record it in operative notes, it is important to know that CVS cannot be said to have been achieved without attainment of all 3 elements of this method of target identification. We dictate these 3 elements into operative notes and recommend it as an excellent practice. ACKNOWLEDGMENT The authors thank Ms Christine A. Vaporean of the law firm of Brown and James, Saint Louis, Missouri, for helpful discussions and suggestions.

Achieving the critical view of safety (CVS) before transection of the cystic artery and duct is important to reduce biliary duct injury in laparoscopic cholecystectomy. To gain more insight into complications after laparoscopic cholecystectomy, we investigated whether the criteria for CVS were met during surgery by analyzing videos of operations performed at our institution. All consecutive patients who underwent a completed laparoscopic cholecystectomy between 2009 and 2011 were included. The videos of the operations of patients with complications were independently reviewed and rated by two investigators with a third consulted in the event of a disagreement. The reviewers answered consecutive questions about whether the CVS criteria were met. Patients who underwent an elective laparoscopic cholecystectomy and had no complications were used as a control group for comparison. Of the 1108 consecutive patients who had undergone a laparoscopic cholecystectomy during the study period, 8.8 % developed complications (average age 51 years) and 1.7 % had bile duct injuries [six patients (0.6 %) had a major bile duct injury, type B, D, or E injury]. In the 65 surgical videos available for analysis, CVS was reached in 80 % of cases according to the operative notes. However, the reviewers found that CVS was reached in only 10.8 % of the cases. Only in 18.7 % of the cases the operative notes and video agreed about CVS being reached. CVS was not reached in any of the patients who had biliary injuries. In the control group, CVS was reached significantly more often in 72 %. In our institutional series of laparoscopic cholecystectomies with postoperative complications, CVS was reached in only a few cases. Evaluating surgical videos of laparoscopic cholecystectomy cases are important and we recommend its use to improve surgical technique and decrease the number of biliary injuries.

Laparoscopic subtotal cholecystectomy for the difficult gallbladder: Evolution of technique at a single teaching hospital

Background Laparoscopic cholecystectomy (LC), introduced in the early 1990s, is now the gold standard for treating gallbladder lithiasis. It offers benefits such as reduced postoperative pain, shorter hospital stays, faster recovery, and lower costs for national healthcare systems, making it a routine surgical procedure. Aim of the Work The study aims to assess the safety of applying the critical view of safety in laparoscopic cholecystectomy, focusing on complications and postoperative stay, among patients at El-Demerdash Hospital from June to December 2023. Patients and Methods This retrospective cohort study will be conducted at the general surgery department of El-Demerdash Hospital from June 2023 to December 2023, aiming to assess the safety of the critical view of safety in laparoscopic cholecystectomy. Results This study aimed to evaluate the effectiveness of the Critical View of Safety (CVS) technique in laparoscopic cholecystectomy by comparing two groups of patients. Group A had CVS applied in 100% of cases, while Group B did not receive this technique. The study focused on postoperative complications and outcomes, providing valuable insights into the role of CVS in improving surgical safety. Both groups were comparable in terms of age, sex, and medical history, ensuring that these factors did not bias the results. The findings revealed a significant difference in the implementation of CVS, with Group A having CVS applied in all cases, while Group B did not receive this technique at all (p < 0.001). This distinction was crucial as CVS is known to reduce the risk of bile duct injuries, a common and severe complication in laparoscopic cholecystectomy. Postoperative complications were absent in Group A, whereas Group B had a 4% complication rate, including bleeding and bile leakage, which highlights the protective effect of CVS in minimizing risks.The study also found that adhesions were the primary cause of complications in Group B (54%), suggesting that CVS may mitigate risks even in challenging cases with prior abdominal surgeries. These results align with existing literature, emphasizing that applying CVS during laparoscopic cholecystectomy significantly reduces the likelihood of complications. Conclusion This study demonstrated that the application of the Critical View of Safety (CVS) technique in laparoscopic cholecystectomy significantly improves patient outcomes by reducing postoperative complications. The results showed that patients in Group A, where CVS was applied in 100% of the cases, had no postoperative complications, whereas Group B, where CVS was not achieved, experienced a 4% complication rate. The findings highlight the crucial role of CVS in minimizing the risk of bile duct injuries and other complications associated with laparoscopic cholecystectomy. The demographic and medical history factors between the two groups were comparable, ensuring that the observed differences in outcomes were primarily due to the implementation of CVS. Given the significant reduction in complications observed in Group A, it is evident that CVS plays an important role in improving the safety of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) is the standard treatment for gallstone-related diseases, but bile duct injury remains a significant complication. This study investigates the efficacy of integrating the Critical View of Safety (CVS) and Indocyanine Green (ICG) fluorescent cholangiography to prevent bile duct injury. A retrospective study was conducted on 50 patients with cholelithiasis and gallstone-related complications who underwent LC at Srinakharinwirot University from April 2022 to April 2024. ICG (2.5 mg) was administered intravenously 60 min prior to surgery. LC was performed using a near-infrared light source. Statistical analysis included Chi-squared, unpaired t-tests, and logistic regression, with a significance level at p < 0.05. CVS was established in 78% of cases. Most cholecystectomies were complete (88%), no major bile duct injuries were reported. Visualization rates for the common bile duct (100%). Patients with gallbladder inflammation or previous history of ERCP had lower visualization rates, but these differences were not statistically significant. The non-CVS group had significantly longer operative times (75.9 vs. 60.5 min; p < 0.001) and higher rates of incomplete cholecystectomy (54.5% vs. 0%; p < 0.001) than the CVS established group. Integrating CVS and ICG fluorescent cholangiography enhances the safety of LC by improving bile duct visualization and reducing the risk of bile duct injury.

Major bile duct injuries occur infrequently after laparoscopic cholecystectomy, but may result in life-threatening complications. Few data exist on the financial implications of duct repair. This study calculated the costs of operative repair in a cohort of patients who underwent reconstruction of the bile duct after major ductal injury. To calculate the total in-hospital cost of surgical repair of patients referred with major bile duct injuries. A prospective database was reviewed to identify all patients referred to the University of Cape Town Private Academic Hospital, South Africa, between 2002 and 2013 for assessment and repair of major laparoscopic bile duct injuries. The detailed clinical records and billing information were evaluated to determine all costs from admission to discharge. Total costs for each patient were adjusted for inflation between the year of repair and 2013. Results. Forty-four patients (33 women, 11 men; median age 48 years, range 30 - 78) underwent reconstruction of a major bile duct injury. First-time repairs were performed at a median of 24.5 days (range 1 - 3,662) after initial surgery. Median hospital stay was 15 days (range 6 - 86). Mean cost of repair was ZAR215,711 (range ZAR68,764 - 980,830). Major contributors to cost were theatre expenses (22%), admission to intensive care (21%), radiology (17%) and specialist fees (12%). Admission to a general ward (10%), consumables (7%), pharmacy (5%), endoscopy (3%) and laboratory costs (3%) made up the balance. The cost of repair of a major laparoscopic bile duct injury is substantial owing to prolonged hospitalisation, complex surgicalintervention and intensive imaging requirements.

The mainstay of therapy for acute cholecystitis is cholecystectomy, which has a mortality of 5-30% in high-risk patients such as the elderly or critically ill. An alternative treatment option in patients suffering from acute cholecystitis with contraindications to emergency surgery is percutaneous cholecystostomy (PC) followed by interval laparoscopic cholecystectomy. Percutaneous cholecystostomy yields 10-12% mortality in high-risk patients and is therefore a safe temporizing measure, allowing delayed, elective cholecystectomy when the patient is in better condition for surgery. Hospital charts and radiology films were reviewed for all 50 patients who underwent PC for acute cholecystitis between January 1990 and September 1993. Most patients were high risk for emergency cholecystectomy by virtue of their critical illness or underlying medical condition. Twenty-five patients went on to have interval cholecystectomies. We recorded whether they underwent laparoscopic or open cholecystectomy, as elective or emergency procedures, and we recorded direct complications, mortality, and postoperative length of hospital stay. Relief of symptoms occurred within 48 h of PC in 90% of patients, and two patients had complications of PC. Laparoscopic cholecystectomy was attempted in 13 patients and competed in nine. Four patients (31%) required conversion from laparoscopic to open cholecystectomies due to extensive adhesions (3) or bleeding (1). Three patients had direct complications of laparoscopic cholecystectomy. There was no mortality or major bile duct injury. Percutaneous cholecystostomy followed by interval laparoscopic cholecystectomy is a safe, minimally invasive approach which can be employed safely in the critically ill patient when contraindications to emergency surgery exist.

To prevent vasculobiliary injuries according to the Tokyo Guidelines, Critical View of Safety (CVS) is the recommended method for the identification of the cystic duct and cystic artery. Our aim was to audit laparoscopic cholecystectomies, in order to determine the rate of CVS feasibility and to explore safe bail-out alternatives, when CVS cannot be obtained. Patients who underwent either elective or emergent laparoscopic cholecystectomy, between January 2009 and December 2018, in whom the CVS was attempted, were retrospectively identified from the institutional electronic database. Dissection technique was documented in the operative notes. Bile duct injuries (BDI) were classified by the Strasberg classification, and their management and outcome were reported in the patient files. In total, 1226 cases were included in the final analysis. CVS was feasible in 1128 cases (92.0%), whereas 65 patients (5.3%) were managed laparoscopically by a bail-out technique. Of those, 52 (4.3%) underwent a subtotal cholecystectomy, 12 (0.9%) a fundus-first cholecystectomy, and in one patient (0.1%) the operation was concluded by a tube cholecystostomy. Overall conversion rate was 2.7% (33/1226 cases). Male gender, older age, junior surgeons, and acute cholecystitis were significantly associated with higher conversion rates. Post-operatively, 10 patients (0.82%) developed a type A bile leakage. No major BDI (types B-E) were observed, either with CVS or the bail-out techniques. Our study showed that CVS and the bail-out alternatives complement each other in preventing major BDI and should belong to the armamentarium of every modern surgeon.

Major bile duct injury (MBDI) is one of the most serious complications associated with laparoscopic cholecystectomy (LC). This study reports our experience in preventing MBDI during LC. Between September 1991 and August 2004, 13,000 cases of LC were performed at Kunming General Hospital. Systemic strategies, including selection of proper patients for LC based on the surgeons' experience, dissection techniques in Calot's triangle, selective use of laparoscopic ultrasonography, and indication of conversion to an open approach were developed and introduced to avoid MBDI. In our series, the overall incidence of MBDI was 0.085%, 0.60% (3 of 500) over the first period from September 1991 to September 1992, 0.17% (5 of 3000) over the second period from October 1992 to September 1996, and 0.03% (3 of 9500) over the third period from October 1996 to August 2004. The MBDI included transection of the common bile duct (CBD) due to mistaking CBD for cystic duct (n=6), cautery injury (n=3), laceration of the CBD at the junction of cystic duct and CBD (n=1), and clip partially of common hepatic duct due to blind hemostasis (n=1). The incidence of MBDI in our institution is acceptable. We believe the system strategies are effective to avoid MBDI in LC. LC is a safe procedure with an incidence of biliary injury comparable with that for open cholecystectomy.

OBJECTIVES: The purpose of this study is to compare the critical view of safety technique with the infundibular technique in laparoscopic cholecystectomy in terms of mean operative time and bile duct injuries (BDI). METHODOLOGY: Between 2018 and 2020, 220 patients had laparoscopic cholecystectomy in the Surgical "A" unit at Hayatabad Medical Complex in Peshawar, Pakistan. The patients were divided into two groups, with the first receiving a critical view of safety and the second receiving an infundibular procedure. Operation time and bile duct injury were compared between the two groups. RESULTS: The operative time was significantly reduced with the critical view of safety (CVS) approach, with a mean time of 35.07 minutes for CVS and 40.58 minutes for infundibular technique, with a significant P-value (0.013). About 17 (7.7%) cases required open cholecystectomy; the conversion rate was higher in the infundibular group, with a significant P-value (&lt;0.001). CONCLUSION: Although the "critical view of safety" requires more patience during dissections than the infundibular approach, it is proven to be faster and is considered a safe procedure in laparoscopic cholecystectomy. KEYWORDS: Critical View of Safety (CVS), Infundibular Technique (IT), Bile Duct Injury (BDI)

The critical view of safety and bile duct injuries in laparoscopic cholecystectomy: a photo evaluation study on 1532 patients

The mechanism and extent of major bile duct injuries following laparoscopic cholecystectomy differ from those of open cholecystectomy. To identify differences in the demographic profile, timing of injury detection, management strategies and outcome, we undertook a retrospective review and analysis of our experience with 55 major bile duct injuries following both laparoscopic and open cholecystectomies over a period of 9 years. Thirty-one major bile duct injuries resulted from laparoscopic cholecystectomy (56%) and 24 of them were sustained after open cholecystectomy (44%). The median time of presentation was 7 days after laparoscopic cholecystectomy and 14 days following open cholecystectomy (P < 0.001). Twenty-eight (51%) patients had injuries recognized intraoperatively in both groups, of whom 18 patients underwent an attempt at primary repair before referral. All patients required subsequent surgical intervention. There were no differences in the clinical presentations between the two groups. However, serum alkaline phosphatase, alanine aminotransferase and aspartate aminotransferase levels were significantly higher following open cholecystectomy (P < 0.05). There was no significant difference in the level of injury between the two groups. All patients underwent surgical repair in the form of a Roux-en-Y hepaticojejunostomy (including two revision hepaticojejunostomies in each group). Surgical outcome did not differ between the groups; however, better results were seen with Bismuth grades 1 and 2 strictures compared with Bismuth grades 3 and 4 strictures for both groups (P < 0.002). Major bile duct injuries following laparoscopic cholecystectomy present earlier and with lower levels of serum alkaline phosphatase, alanine aminotransferase and aspartate aminotransferase. There does not appear to be a significant difference between the Bismuth-Strasberg grading of the strictures and the type of surgery carried out.

Laparoscopic cholecystectomy has essentially replaced open cholecystectomy as the procedure of choice for gallbladder disease. This rapid shift to laparoscopic cholecystectomy, however, has resulted more from marketing forces than from prospective clinical trials. To evaluate the safety and efficacy of laparoscopic cholecystectomy, the first 486 laparoscopic cholecystectomies at two institutions were studied. These results were then compared to the results of the last 6 months of elective open cholecystectomy cases prior to the introduction of laparoscopic surgery. The age, sex, height, and weight were similar in both groups. The mean operative time was 78.8 +/- 1.8 min for laparoscopic cholecystectomy and 62.7 +/- 2.6 min for open cholecystectomy (p < 0.01). The mean time for tolerating a regular diet was 1.23 +/- 0.04 days in the laparoscopic group versus 2.44 +/- 0.07 days in the open group (p < 0.01). Laparoscopic cholecystectomy patients required only oral pain medications by a mean of 1.22 +/- 0.03 days postoperatively compared to 2.55 +/- 0.07 days postoperatively for those undergoing open cholecystectomy (p < 0.01). The mean length of hospitalization was 1.58 +/- 0.07 days for laparoscopic patients and 3.55 +/- 0.11 days for open patients (p < 0.01). Thirty-one patients undergoing laparoscopic cholecystectomy were converted to open cholecystectomy (6.4%). The most common reasons for conversion to open cholecystectomy were acute inflammation, adhesions, and bleeding. For the laparoscopic patients, the morbidity rate was 8.4% and the mortality rate 0.2% (1 death). In the open cholecystectomy group the morbidity rate was 8.0% and there were no deaths. The most troublesome complication in laparoscopic cholecystectomies continues to be bile leaks and bile duct injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

In cases of severe inflammation, fibrosis, or distorted anatomy, achieving a "Critical View of Safety" during laparoscopic cholecystectomy is often impossible, which significantly increases the risk of catastrophic bile duct injury. The laparoscopic subtotal cholecystectomy is a very important bailout operation in that complete cholecystectomy cannot be performed in a challenging injury of the gallbladder due to extreme inflammation or the absence of anatomy. This retrospective BMHRC Bhopal (January 2024-January 2025) retrospective study looked at 55 patients with a combination of indications, such as chronic calculouscholecystitis, Mirizzi syndrome, gallbladder perforation and post-ERCP situation, with a mean of 78.5 ± 24.3 minutes of operative time, 4.2 ± 2.8 days of hospital stay and a complication rate of 12 per cent, 2 per cent Modified laparoscopic subtotal cholecystectomy is a safe and effective compromised surgical procedure where avoidance of great bile duct injury is a priority and where operative variables, postoperative complications and minimized final outcome are satisfactory with 8.7 ± 3.2 months at the mean follow-up.

Background: The critical view of safety (CVS) has been increasingly recognized as the standard method for identification of different cystic structure and to prevent any vascular or biliary injuries during laparoscopic cholecystectomy operation. Objective: To observe the percentage of patients in whom CVS was attained during laparoscopic cholecystectomy, percentage of patients where bail out procedures were needed and the type of bail out procedure adopted. Methods: This prospective, observational study was conducted in the Department of Minimal Access and General Surgery, Govt. Medical College Srinagar at Kashmir in India, over a period of 6 months. A total of 55 patients of symptomatic cholelithiasis, aged &gt;20 years were enrolled in this study. The said patients were followed up for a period of 6 weeks in the post operative time. Results: 29(52.73%) of the patients were in the age group of 40-59 years, followed by 16(29.09%) in 20-39 years age group. Female predominance was observed as male-female ratio was 1:5. Critical view of safety (CVS) was attained in 50 patients (90.9%), while 5 patients had difficulties: difficulty in dissection of calot’s triangle in 5 cases, dense adhesions were found in 3 cases and 1 had perforated gallbladder. Significant differences were observed between two groups (CVS attained and not attained) in terms of operative time, gallbladder wall thickness and total hospital stay (p&lt;0.001). However, no complications like bile duct injuries or mortality were observed in our study. Bail out procedures were opted – conversion to open cholecystectomy in 3 cases (60%) and laparoscopic fundus first cholecystectomy in 2 cases (40%). Conclusion: Even after adopting all these strategies of critical view of safety (CVS), the surgeons often fail to secure safety in some cases in laparoscopic cholecystectomy due to difficulty in handling gall bladder in situ.International Journal of Human and Health Sciences Vol. 09 No. 01 Jan’25 Page: 48-52