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Feasibility and Value of the Critical View of Safety in Difficult Cholecystectomies.

B ile duct injuries still complicate 0.1% to 0.6% of laparoscopic cholecystectomies, with potential additional morbidity caused by associated hepatic artery injury. As stressed by numerous scientific consensuses worldwide, safe cholecystectomy entails secure anatomy identification through the establishment of the critical view of safety (CVS) before clipping any biliary structures. To prevent misidentification one should clear the hepatocystic triangle, visualize 2 and only 2 anatomical structures entering the gallbladder, and expose the bottom third of the cystic plate. In case of severe inflammation of the porta hepatis and gallbladder neck, establishment of the CVS is challenging. Scarce evidence exists that reaching CVS is of help in such situations. Adjunctive intraoperative imaging and change of the surgical approach have been advocated for these potentially dangerous cases. The video, http://links.lww.com/SLA/B524 associated with the present report shows how the CVS prevents biliary and arterial injuries in a difficult cholecystectomy. In this grade I, mild, acute cholecystitis, diffuse inflammatory adhesions made dissection complex. However, according to the scoring system proposed by Stanford and Strasberg, the operator achieved a 6/6 CVS revealing an unknown vascular variant at the partially exposed cystic plate. This generates the hypothesis that even in difficult cases, when anatomic structures are less well defined and the risk of biliary and vascular complications is higher, the CVS can still be achieved by gentle, careful dissection, and it is of great value. Achieving the CVS in difficult cholecystectomy is a brilliant example of how being systematic, in surgery as in aviation, helps to minimize risks. Laparoscopic cholecystectomy is among the most common laparoscopic procedures performed worldwide, and even if the incidence of vascular and biliary injuries is low, the burden of these