Anticipating critical view of safety challenges in laparoscopic cholecystectomy for symptomatic cholelithiasis patients: Can we predict them earlier?

Abstract

Objective: Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic cholelithiasis. Identifying the critical view of safety (CVS) is crucial in this procedure to prevent complications, but achieving CVS can be challenging, necessitating bailout procedures. This study analyzes factors influencing CVS identification and describes bailout procedures used when CVS identification fails.

Material and methods: We collected data from symptomatic cholelithiasis patients undergoing LC at Cipto Mangunkusumo Hospital from January to October 2023. Factors contributing to CVS identification failure were analyzed, and bailout procedures were described.

Results: Among 107 symptomatic cholelithiasis patients, the mean age was 50.38 years, with the majority being female (55.14% of whom were female). CVS was identified in 88 patients (82.24%). Univariate analysis showed that history of endoscopic retrograde cholangiopancreatography (ERCP) [odds ratio (OR) 5.46], Bile duct (BD) stent (OR 16.53), and diagnosis of cholecystitis (acute, OR 6.17; chronic; OR 4.00) significantly increased CVS identification failure risk. Multivariate analysis identified BD stent as the only significant risk factor (OR 7.41). Higher failure rates were associated with Parkland scores of 4-5, Nassar scores of 4, and G10 scores of 4-5. Among those with CVS identification failure, 5 completed cholecystectomy via top-down approach, 6 underwent subtotal fenestrating cholecystectomy, 6 underwent subtotal reconstituting cholecystectomy, and 2 converted to open cholecystectomy.

Conclusion: Predicting CVS identification failure using preoperative parameters and intraoperative scoring systems is crucial for anticipating surgical complexity and ensuring timely intervention. History of ERCP, BD stent presence, and cholecystitis diagnosis were significant predictors of CVS identification failure. Intraoperative scoring systems reliably predicted CVS identification failure.