How to prevent complications in laparoscopic cholecystectomy: a critical view of safety

Laparoscopic cholecystectomy is associated with a higher incidence of biliary/vasculary injuries than open cholecystectomy. Anatomical misperception is the most common underlying mechanism of such injuries. The critical view of safety (CVS) has been shown to be a good way of getting secure anatomical identification. It is highly recommended by various guidelines. Conceptually, CVS is a method of target identification, with the targets being the two cystic structures. It entails three basic steps as follows: 1) complete clearance of fibrous and fatty tissue from the hepatocystic triangle, 2) separation of the lower part of the gallbladder from the cystic plate, so that 3) two and only two structures are seen entering the gallbladder. Sometimes, anatomic identification is not possible because the risk of biliary injury is judged to be too great. The critical view of safety can be achieved in most cases during laparoscopic cholecystectomy. However, its poor understanding and low adoption rates among practicing surgeons have been global problems. Increasing awareness about the critical view of safety can increase its use in routine surgical practice.