title: Critical view of safety during laparoscopic cholecystectomy.
abstract: OBJECTIVE
  Laparoscopic cholecystectomy has a 0.3% to 0.5% morbidity rate due to major biliary injuries. The majority of surgeons have routinely performed the so-called "infundibular" technique for gallbladder hilar dissection since the introduction  of laparoscopy in the early nineties. The "critical view of safety" approach has only been recently discussed in controlled studies. It is characterized by a blunt dissection of the upper part of Calot's space, which does not usually contain arterial or biliary anomalies and is  therefore ideal for a safe dissection, even in less experienced hands.
  
  
  METHODS
  We applied and compared the critical view of safety triangle approach with the infundibular approach in a retrospective cohort study. We divided 174 patients into 2 groups, with a similar  case-mix (cholelithiasis, chronic cholecystitis, and acute cholecystitis). Results of operations performed by a young surgeon using critical view of safety dissection were compared to results of the infundibular approach performed by an experienced surgeon. Outcome values and operative times  were examined with univariate analysis (Student t test).
  
  
  RESULTS
  No difference occurred in terms of morbidity (even though comparison for biliary injuries is inconclusive because of insufficient power) and outcome; significant differences were found in operative time, favoring  the critical view of safety approach in every stage of gallbladder disease, with minor significance for acute cases.
  
  
  CONCLUSIONS
  We suggest this technique as the gold standard for resident teaching, because it has a similar rate of biliary and hemorrhagic complications but has a  shorter operative time, builds self-confidence, and is a simple standardized method both for complicated and uncomplicated gallbladder lithiasis.
authors: Laparoscopic Surgery, M. Mellini Hospital, V. le Mazzini 4, 25032, Chiari (BS), Italy. nereovet@gmail.com
authors: Nereo
authors: N
authors: Vettoretto
authors: Cristiano
authors: C
authors: Saronni
authors: Asaf
authors: A
authors: Harbi
authors: Luca
authors: L
authors: Balestra
authors: Lucio
authors: L
authors: Taglietti
authors: Maurizio
authors: M
authors: Giovanetti
mesh_terms: D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods; D002764:Cholecystitis / Q000601:surgery; D002769:Cholelithiasis / Q000601:surgery; D006801:Humans; D012189:Retrospective Studies