Critical view of safety approach vs. infundibular technique in laparoscopic cholecystectomy, which one is safer? A systematic review and meta-analysis

Laparoscopic cholecystectomy (LC) remains the gold standard procedure for the management of benign gallbladder disease. Recognizing the need to mitigate complications, mainly bile duct injury (BDI), various techniques for ductal identification during LC have emerged, including the "Critical View of Safety" (CVS) and the infundibular technique (IT). In this systematic review and meta-analysis, we assess and compare the outcomes of both techniques, with a primary focus on evaluating their impact on BDIs. A comprehensive search was conducted using PubMed and Scopus databases. The search focused on the surgical technique, incidences of minor and major BDIs, operative time, conversion rate, and length of stay, among patients undergoing LC for benign gallbladder disease. Our initial search retrieved 264 studies. After screening the unique studies against our predefined inclusion/exclusion criteria, only five met our criteria and were included. Additionally, a manual search identified eight more relevant studies, bringing the total number of included studies to 13. The total number of included patients was 4,837. Approximately two-thirds underwent LC using the CVS approach (61.1%), and 66.3% were female, with a mean age of 44.4 +/- 11.2 years. The CVS approach was associated with a significant reduction in overall BDIs (RR = 0.36; 95% CI 0.18-0.71) and major BDIs (RR = 0.28; 95% CI 0.13-0.63). However, there were no significant differences in terms of minor BDIs, operative time, conversion rates, or length of stay. Our study demonstrated the superiority of the CVS approach in terms of reducing the incidence of overall and major BDIs compared to IT. However, our study revealed no other significant differences between the two techniques. Further research, including multicentric randomized controlled trials, will be necessary to further evaluate the efficacy of these techniques.