Analysis of Failure to Achieve the Critical View of Safety (CVS) in Laparoscopic Cholecystectomy: A Prospective Observational Study

Background The critical view of safety (CVS) is the principal intraoperative strategy to prevent bile duct injury during laparoscopic cholecystectomy (LC). However, CVS may not be achieved in all cases. Factors that predict such failure remain understudied. The aim of this study was to determine the rate of failure to achieve CVS during LC and to identify various preoperative and intraoperative predictors of failure to achieve CVS. Methods In this prospective observational study, 41 adult patients undergoing LC for gallstone disease at a single center were included. LC was performed using the standard four-port technique by a single hepatobiliary surgeon utilizing the CVS approach. Various preoperative variables, including the Gall Bladder Reporting and Data System (GB-RADS) score and Cholecystectomy Laparoscopic-to-Open Conversion (CLOC) score, and intraoperative variables, including the modified Nassar grade, were recorded. Univariable tests and multivariable logistic regression analysis were performed to determine various predictors of failure to achieve CVS. Results A total of 41 patients with a mean age of 41.66±11.74 years were included in the study. There were 30 (73.2%) females. The most common indication for LC was biliary colic in 25 (60.9%) cases. The CVS could not be achieved in 6 (14.63%) cases. These six failures were managed with subtotal cholecystectomy (laparoscopically in four and open in two). The overall conversion rate was 2 (4.87%). On univariable analysis, raised serum alkaline phosphatase (p=0.012) and serum gamma-glutamyl transferase (p=0.047) as preoperative laboratory parameters, the presence of pericholecystic fluid (p=0.026) and a higher GB-RADS score (p=0.010) as imaging features, and limited extension of the gallbladder fundus in relation to the liver edge (till/short of liver edge) (p=0.008) and a fibrotic gallbladder bed (p < 0.005) as intraoperative findings were factors found to be associated with failure to achieve CVS. On multivariable analysis, a GB-RADS score of 2 (odds ratio (OR) 8.74) and a fibrotic gallbladder bed (OR 10.04) were found to be independent predictors of failure to achieve CVS. The total CLOC score was independently predictive (OR 26.6) and discriminated failure to achieve CVS better than the modified Nassar grade (area under the curve, 0.788 vs. 0.704). Conclusions The CVS can be achieved in a majority of cases during LC. A higher GB-RADS score, a fibrotic gallbladder bed, and a higher CLOC score can identify at-risk patients and may aid preoperative planning and readiness for early bailout.