DOI: 10.1177/15533506261476209 ISSN: 1553-3506

Beyond Critical View of Safety: New Predictors of Objective Assessment of Critical View of Safety in Laparoscopic cholecystectomy—a Prospective Cohort Study

Ravi Gupta, Aditya Gaurav, Gaurav Gupta, Rama Shankar Rath, Dharmendra Kumar Pipal, Mukul Singh, Harikesh Yadav, Rajnish Kumar, Manish Kumar, Aishwarya Priyadarsani Bhuyan, Swati Prasad
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Background

Laparoscopic cholecystectomy (LC) has revolutionised gallstone management. However, the incidence of bile duct injury (BDI) remains unchanged. Achieving the critical view of safety (CVS) is the standard endpoint of LC dissection to prevent BDI. This study aimed to identify preoperative, intraoperative, and novel predictors of CVS quality using intraoperative doublet photography.

Methods

This prospective, single-centre observational study (March 2024–January 2025) evaluated CVS achievement in patients undergoing elective LC. Experienced surgeons assessed anterior and posterior view photographs. We analysed predictors of CVS quality, including novel parameters such as critical angle, critical distance, and critical area ratio.

Results

The study included 64 patients undergoing elective LC. CVS was satisfactory in 82.8% (53) and unsatisfactory in 17.2% (11) of the participants. Significant predictors of CVS quality included preoperative biochemical factors like erythrocyte sedimentation rate (OR: 4.06, 95% CI: 0.96-17.09, P = .05) and alanine aminotransferase (OR: 5.48, 95% CI: 1.81-25.47, P = .02); radiological findings including stone impacted at gall bladder neck (OR: 9.52, 95% CI: 1.75-51.77, P = .009); intraoperative variables such as modified Nassar grade (OR: 7.42, 95% CI: 1.72-32.00, P = .007) and Hartmann’s pouch stone (OR: 4.47, 95% CI: 1.00– 19.93, P = .04); and certain novel parameters including critical angle ratio anterior (AOR: 9.87, 95% CI: 1.1-83.12, P = .03).

Conclusions

This observational study introduces simple metrics for objective CVS assessment using novel parameters such as critical angle, distance, and area to improve grading accuracy. These parameters may support artificial intelligence tools for intraoperative CVS quality assessment, promoting safer cholecystectomy and contributing to a standardised grading system.

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