title: Are we getting the critical view? A prospective study of photographic documentation during laparoscopic cholecystectomy.
abstract: BACKGROUND
  At laparoscopic cholecystectomy, most surgeons have adopted the operative approach where the 'critical view of safety' (CVS) is achieved prior to dividing the cystic duct and artery. This prospective study evaluated whether an adequate critical view was achieved by scoring standardized intra-operative photographic views and whether there were other factors that might impact on the ability to obtain an adequate critical view.
  
  
  METHODS
  One hundred consecutive patients undergoing a laparoscopic cholecystectomy were studied. At each operation, two photographs were taken. Two independent experienced hepatobiliary surgeons scored the photographs on whether a critical view of safety was achieved. Inter-observer agreement was calculated using the weighted kappa coefficient. The Cochran-Mantel-Haenszel test was used to analyse the scores with potential confounding clinical factors.
  
  
  RESULTS
  The kappa coefficient for adequate display of the cystic duct and artery was 0.49; 95% confidence interval (CI) 0.33 to 0.64; P = 0.001. No bias was detected in the overall scorings between the two observers (χ(2) 1.33; P = 0.312). Other clinical factors including surgeon seniority did not alter the outcome [odds ratio (OR) 0.902; 95% confidence interval 0.622 to 1.264].
  
  
  CONCLUSIONS
  Heightened awareness of the CVS through mandatory documentation may improve both trainee and surgeon technique.
authors.affiliation: Department of Surgery, Western Health, Melbourne, Victoria, Australia.
authors.forename: Tracey
authors.initials: T
authors.lastname: Lam
authors.forename: Val
authors.initials: V
authors.lastname: Usatoff
authors.forename: Steven T F
authors.initials: ST
authors.lastname: Chan
mesh_terms: D000328:Adult; D000368:Aged; D001158:Arteries / Q000601:surgery; D016009:Chi-Square Distribution; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects; D002983:Clinical Competence; D003549:Cystic Duct / Q000601:surgery; D004282:Documentation / Q000379:methods*; D005260:Female; D005704:Gallbladder / Q000098:blood supply* / Q000601:surgery*; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D016017:Odds Ratio; D010781:Photography; D011183:Postoperative Complications / Q000517:prevention & control; D011446:Prospective Studies; D015203:Reproducibility of Results; D016896:Treatment Outcome