# Scale and Safety: Analyzing the Association Between Intraoperative Difficulty and Achieving the Critical View of Safety in Laparoscopic Cholecystectomy

## TL;DR

This study shows that achieving the critical view of safety during laparoscopic gallbladder surgery is linked to easier procedures and fewer complications.

## Contribution

The study demonstrates a novel association between achieving the critical view of safety and reduced intraoperative difficulty in laparoscopic cholecystectomy.

## Key findings

- Achieving the critical view of safety is associated with lower rates of higher-grade operative difficulty.
- Patients who achieved the critical view of safety had shorter hospital stays.
- Baseline demographics and disease characteristics did not differ between groups.

## Abstract

Background: Laparoscopic cholecystectomy (LC) is the preferred method for gallstone removal, but bile duct injuries remain a concern. Achieving the critical view of safety (CVS) is pivotal in preventing such injuries. The aim of this study was to compare the rates of difficult LC in those with CVS achieved compared to those with CVS not achieved.

Methods: We performed a single-center prospective study on all patients with ultrasound-confirmed symptomatic gallstones. Patients were excluded if they refused to consent or if they underwent LC for indications other than gallstone disease. Patients were stratified into two groups as CVS not achieved and CVS achieved groups and compared for outcomes. Our primary outcome was the rate of intraoperative difficulty on the modified Nassar scale (MNS). Statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY).

Results: We included 70 patients who underwent LC for gallstones (CVS not achieved = 24 and CVS achieved = 46). The mean (SD) age was 42.2 (12.3) years, and 73.5% were females. The mean (SD) weight in our study cohort was 74.1 (10.9) kg, and there was no difference between the two groups in terms of the baseline demographic characteristics, disease characteristics, and comorbid conditions (p > 0.05). On univariate analyses, achieving CVS was associated with lower rates of higher-grade operative difficulty on the MNS and lower rates of length of stay of more than one day.

Conclusion: Achieving CVS is associated with easy LC based on significantly lower Nassar scores. These findings highlight the role of the MNS in the successful identification of the operative difficulty of LC and its correlation with achieving CVS.