Factors Predictive of Achieving Critical View of Safety in Laparoscopic Cholecystectomy in A Tertiary Care Hospital

Abstract

Objective: To determine the proportion of LC cases in which CVS is achieved and to identify preoperative and intraoperative factors predictive of its achievement.

Methodology: This Cross-sectional study was conducted from April to September 2024 at Islamabad Medical Complex, enrolling 152 consecutive adult patients undergoing elective or emergency LC for benign gallbladder pathology. CVS was defined according to SAGES criteria. Data on demographic, preoperative, intraoperative, and postoperative variables were collected using a structured proforma. Operative difficulty was graded using the modified Nassar scale.

Results: The mean patient age was 46.6 ± 14.5 years, with a male-to-female ratio of 1:2.3. CVS was achieved in 117 cases (77%) and not achieved in 35 cases (23%). Preoperative gallbladder wall thickening >3 mm was significantly associated with CVS failure (p = 0.03). Intraoperative factors linked to CVS non-achievement included higher operative difficulty grades III–V (p < 0.001), severe gallbladder pathology such as mucocele/empyema/gangrene/Mirizzi (p < 0.001), adhesions with the duodenum (p < 0.001) or colon (p = 0.02), abnormal Calot’s triangle anatomy (p = 0.04), operative time >1 hour (p < 0.001), cystic duct ligation with sutures (p < 0.001), non-complete cholecystectomy (p < 0.001), and drain placement (p < 0.001). Postoperatively, CVS non-achievement was associated with prolonged antibiotic use (p = 0.02) and longer hospital stay (p < 0.001). No BDI or conversions occurred.

Conclusion: CVS can be achieved in most LC cases, but its likelihood is reduced by preoperative gallbladder wall thickening, higher operative difficulty grades, severe inflammatory pathology, adhesions, and abnormal anatomy. Early recognition of these predictors facilitates surgical planning, timely use of bail-out strategies, and improved patient safety.

Keywords: Laparoscopic cholecystectomy, Critical View of Safety, bile duct injury, predictors, operative difficulty, gallbladder pathology