The clinical importance of the critical view of safety in laparoscopic cholecystectomy

Background: Injury of the bile duct during cholecystectomy (CHE) is a severe complication. The critical view of safety (CVS) can help to reduce the frequency of this complication during laparoscopic CHE. So far, no scoring of CVS images with a grading system is available.Method: The CVS images of 534 patients with laparoscopic CHE could be structurally analyzed and assessed with marks from 1 (very good) to 5 (insufficient). The CVS mark was correlated with the perioperative course. Additionally, the perioperative course of patients after laparoscopic CHE with and without a CVS image was investigated.Results: In 534 patients 1 or more CVS images could be analyzed. The average CVS mark was 1.9, whereby 280 patients (52.4%) had a 1,126 patients (23.6%) a 2,114 (21.3%) a 3 and 14 patients (2.6%) a 4 or 5. Younger patients with elective laparoscopic CHE had CVS images significantly more frequently (p <= 0.04). The statistical examination with Pearson's chi(2)-test and the F-test (ANOVA) showed a significant correlation between improving CVS marks and reduction of surgery time (p < 0.01) and the hospitalization time (p < 0.01). For senior physicians the quota of CVS images ranged from 71% to 92% and the average marks from 1.5 to 2.2. The marks for the CVS images were significantly better for female than male patients (1.8 vs. 2.1, p < 0.01).Discussion: There was a relatively broad distribution of marks for CVS images. Injuries of the bile duct can be avoided with a high degree of certainty with marks 1-2 for the CVS image. The CVS is not always adequately visualized in laparoscopic CHE.