Ten-year Audit of Safe Bail-Out Alternatives to the Critical View of Safety in Laparoscopic Cholecystectomy

Background 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. Methods 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. Results 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. Conclusions 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.