Critical View of Safety in Laparoscopic Cholecystectomy: Prospective Evaluation Using Doublet Photography

Abstract

Background:

This study aimed to see the percentage of achievability of Critical View of Safety (CVS), using a doublet photograph technique in a tertiary care center, and identify factors beyond the surgeon in terms of the gender, age, socioeconomic status, and pathology of the disease.

Methods:

This prospective observational study analyzed 356 laparoscopic cholecystectomy cases performed by 2 experienced surgeons (>500 cases). A validated scoring system assessed three CVS criteria: identification of two structures connected to the gallbladder, the cystic plate, and hepatocytic triangle clearance. CVS was deemed satisfactory with a mean score ≥5.0, evaluated intraoperatively by the surgeon and independently scored by another. Patients’ socioeconomic status was measured by the modified Kuppuswamy scale, and intraoperative findings were correlated with CVS attainment.

Results:

The CVS was attained in 56.64% of cases. Socioeconomic status showed a weak association with CVS achievement (Cramér’s V = 0.155, P = .073), with lower-class patients disproportionately represented in the “No CVS” group (residual = 1.73). Intraoperative factors significantly impacted CVS attainment, with short cystic ducts, large stones at the neck, and severe adhesions reducing success rates. Acute cholecystitis (β = −1.40, P < .001) and empyema (β = −1.66, P < .001) negatively impacted CVS, while blue/dull gallbladder (β = + 1.10) improved it.

Conclusion:

The attainability of the CVS using the doublet photograph technique is low, with satisfactory CVS achieved in only slightly more than half of cases. Despite experienced surgeons, patient-related factors and intraoperative difficulties—particularly acute cholecystitis, empyema, and severe adhesions—significantly limited CVS attainment. These findings indicate that the doublet photograph technique alone is insufficient to reliably ensure CVS, emphasizing the need for early intervention and adjunctive safety strategies during difficult cholecystectomies.