The critical view of safety (CVS) is a surgical technique that was developed to help reduce the risk of complications during laparoscopic cholecystectomy, which is the removal of the gallbladder using minimally invasive techniques. CVS involves ensuring a clear and unobstructed view of the anatomical structures of the gallbladder, including the cystic duct and the cystic artery, before proceeding with their dissection and division.

The three components of the CVS are:

Visualization of the cystic duct and artery: The surgeon must clearly visualize both the cystic duct and cystic artery before they are clipped and divided.

Dissection of the gallbladder from the liver bed: The surgeon must carefully dissect the gallbladder from the liver bed, ensuring that no other structures are being dissected.

Confirmation of the safety of the dissection: The surgeon must confirm that the dissection has been done safely before the gallbladder is removed.

By using the CVS technique, surgeons aim to reduce the risk of complications such as bile duct injury, bleeding, and bile leak, which can occur during laparoscopic cholecystectomy. The critical view of safety is now considered a standard of care during laparoscopic cholecystectomy and is recommended by many surgical societies and guidelines.

Achieving a critical view of safety (CVS) during Laparoscopic Cholecystectomy is crucial to avoid complications such as bile duct injury, but it is not always possible due to factors such as abnormal anatomy, inflammation, or stone impaction. Patients who are identified as having a higher risk of difficult Laparoscopic Cholecystectomy, based on preoperative tests such as neutrophil percent, lymphocyte percent, and abdominal ultrasound, should be operated on by experienced senior surgeons who can employ alternate surgical approaches or bailout procedures and may require intraoperative biliary imaging. Identifying difficult cases preoperatively can also help to refer patients to higher centers with expertise.

Studies have shown that the ability to achieve CVS is the most important factor in intraoperative decision-making and postoperative outcomes, as proceeding without achieving it is the most common cause of bile duct injury. Therefore, it is essential to identify patients who may be at risk for difficult CVS preoperatively to ensure that the procedure is performed safely by experienced surgeons. In addition, the study discusses alternative techniques that can be used when CVS cannot be achieved.

Laparoscopic Cholecystectomy is a widely performed surgical procedure, but bile duct injury is a serious complication that can occur. To prevent this, meticulous dissection and CVS must be achieved. When CVS is not possible, patients at risk for difficult Laparoscopic Cholecystectomy should be operated on by experienced surgeons with alternative techniques available. Identifying patients at risk preoperatively is essential for improving outcomes and reducing complications.