title: How often do surgeons obtain the critical view of safety during laparoscopic cholecystectomy?
abstract: The reported incidence (0.16-1.5 %) of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is higher than during open cholecystectomy and has not decreased over time despite increasing experience with the procedure. The "critical view of safety" (CVS) technique may help to prevent BDI when certain criteria are met prior to division of any structures. This study aimed to evaluate the adherence of practicing surgeons to the CVS criteria during LC and the impact of a training intervention on CVS identification.
  
  
  
  LC procedures of general surgeons were video-recorded. De-identified recordings were reviewed by a blinded observer and rated on a 6-point scale using the previously published CVS criteria. A coaching program was conducted, and participating surgeons were re-assessed in the same manner.
  
  
  
  The observer assessed ten LC videos, each involving a different surgeon. The CVS was adequately achieved by two surgeons (20 %). The remaining eight surgeons (80 %) did not obtain adequate CVS prior to division of any structures, despite two surgeons dictating that they did; the mean score of this group was 1.75. After training, five participating surgeons (50 %) scored > 4, and the mean increased from 1.75 (baseline) to 3.75 (p < 0.05).
  
  
  
  The CVS criteria were not routinely used by the majority of participating surgeons. Further, one-fourth of those who claimed to obtain the CVS did so inadequately. All surgeons who participated in training showed improvement during their post-assessment. Our findings suggest that education of practicing surgeons in the application of the CVS during LC can result in increased implementation and quality of the CVS. Pending studies with larger samples, our findings may partly explain the sustained BDI incidence despite increased experience with LC. Our study also supports the value of direct observation of surgical practices and subsequent training for quality improvement.
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, Carolinas HealthCare System, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC, 28204, USA. dimitrios.stefanidis@carolinashealthcare.org.|Carolinas Simulation Center, Carolinas HealthCare System, Charlotte, NC, USA. dimitrios.stefanidis@carolinashealthcare.org.|University of North Carolina, Chapel Hill, NC, USA. dimitrios.stefanidis@carolinashealthcare.org.
authors.forename: Dimitrios
authors.identifier: 0000-0002-2177-0763
authors.initials: D
authors.lastname: Stefanidis
authors.affiliation: Division of Quality, Carolinas HealthCare System, Charlotte, NC, USA.
authors.forename: Nikita
authors.initials: N
authors.lastname: Chintalapudi
authors.affiliation: Division of Quality, Carolinas HealthCare System, Charlotte, NC, USA.
authors.forename: Brittany
authors.initials: B
authors.lastname: Anderson-Montoya
authors.affiliation: Division of Bariatric Surgery, Department of Surgery, Carolinas HealthCare System, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC, 28204, USA.
authors.forename: Bindhu
authors.initials: B
authors.lastname: Oommen
authors.affiliation: Carolinas Simulation Center, Carolinas HealthCare System, Charlotte, NC, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Tobben
authors.affiliation: Carolinas Simulation Center, Carolinas HealthCare System, Charlotte, NC, USA.
authors.forename: Manuel
authors.initials: M
authors.lastname: Pimentel
mesh_terms: D000328:Adult; D001652:Bile Ducts / Q000293:injuries; D017081:Cholecystectomy, Laparoscopic / Q000193:education / Q000379:methods*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D008297:Male; D010865:Pilot Projects; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D058996:Quality Improvement; D066231:Surgeons; D014741:Video Recording
keywords: Coaching; Performance assessment; Simulation training; Surgery; Video