Gallbladder diseases often present as gallstones, gallbladder inflammation, or gallbladder cancer. Cholecystectomy has long been the gold-standard surgical treatment for cholelithiasis and cholecystitis. The rationale for gallbladder removal lies not in the presence of stones but in its role in stone formation. The advent of laparoscopic surgery has brought about a significant revolution in managing gallbladder disease [1, 2, 3]. Open cholecystectomy, a longstanding surgical approach unchallenged for over a century, saw a dramatic shift with the introduction of laparoscopic cholecystectomy. Traditionally, open surgical removal had been reserved as a final therapeutic option for symptomatic cholelithiasis prior to the emergence of laparoscopy. In contrast, lithotripsy and cholecystectomy were more commonly favored as less invasive alternatives [4].

Laparoscopic procedures have demonstrated several advantages, including reduced pain, shorter recovery periods, less operative stress, and limited inflammatory responses. Bile duct injuries typically present as either biliary leaks or obstructions. In recent decades, surgeons have dedicated significant efforts to develop a safe approach to dissection in Calot’s triangle and the identification of the cystic duct.

The Critical View of Safety (CVS) technique serves as a method for precisely identifying key targets, namely, the cystic duct and the cystic artery [5, 6]. Therefore, the aim of this current study was to evaluate the effectiveness of the Critical View of Safety in laparoscopic cholecystectomy for its ability to prevent bile duct injuries. The current study was conducted within the Department of General Surgery, focusing on evaluating the effectiveness of achieving the critical view of safety during laparoscopic cholecystectomy to prevent bile duct injury. Seventy consecutive patients diagnosed with gallbladder disease were enrolled in the study. Exclusion criteria for the study were as follows:

• Pregnant subjects,
• Patients with bleeding disorder,
• Patients with cirrhosis with portal hypertension,
• Patients with generalized peritonitis.

Comprehensive demographic information for every patient was meticulously collected. Preoperatively, a hematological and biochemical profile analysis was conducted for all patients. Subsequently, laparoscopic cholecystectomy was performed on all enrolled patients, and highly skilled and experienced surgeons carried out these procedures. Following surgery, a thorough post-operative assessment was conducted.

To assess the level of significance, statistical analysis was performed using the Chi-square test and the Mann-Whitney \(U\) test. A \(p\)-value of less than 0.05 was considered statistically significant.

In the present study, 50 percent of the patients fell within the age group of 20 to 50 years, with the average age being 48.6 years. Of the patients, 80 percent were females, while the remaining 20 percent were males. Pain was the predominant clinical symptom, observed in 100 percent of the patients. Dyspepsia and vomiting were also reported, with prevalence rates of 46.67 percent and 5.33 percent, respectively.

Aberrant anatomy was detected in two patients, while 68 patients had typical anatomical structures. Spillage occurred in 25.33 percent of the patients, but was absent in 74.67 percent of the cases. Notably, the Critical View of Safety was successfully achieved in 100 percent of the patients in this study. Aberrant anatomy was encountered only in two cases, which subsequently required conversion to open cholecystectomy. The average duration of the procedure in the present study was 59.45 minutes.

In accordance with the research methodology, the study population has been systematically categorized and analyzed across various parameters. The distribution of subjects has been delineated based on age groups, and the relevant findings are documented in Table 1. Furthermore, the investigation extends to the assessment of aberrant anatomy among patients, with a detailed breakdown presented in Table 2. The distribution of patients, categorized according to the presence or absence of spillage during the procedure, is comprehensively documented in Table 3. Lastly, the attainment of the Critical View of Safety (CVS) is rigorously examined and detailed in Table 4.

Three specific criteria characterize the Critical View of Safety. Firstly, Calot’s triangle should be meticulously cleared of any fat and fibrous tissue on its dorsal and ventral aspects. Importantly, this step does not necessitate the exposure of the common bile duct. The second criterion entails the separation of the lowest part of the gallbladder from the cystic plate. Lastly, only two structures, and no more, should be visible entering the gallbladder. Once these criteria are met, the Critical View of Safety has been successfully achieved [7, 8, 9]. Therefore, the primary objective of our present study was to evaluate the effectiveness of achieving the Critical View of Safety during laparoscopic cholecystectomy in preventing bile duct injuries. Our present study observed that 50 percent of the patients fell within the age bracket of 20 to 50 years, with the average age being 48.6 years. Of the patients, 80 percent were females, while the remaining 20 percent were males. The most prevalent clinical symptom among patients in our study was pain, which was reported by 100 percent of the patients. Dyspepsia and vomiting were also observed, with prevalence rates of 46.67 percent and 5.33 percent, respectively.

In a study by Singh et al. [10], they assessed the frequency and relevance of anatomical variations in the extrahepatic biliary system among patients undergoing laparoscopic cholecystectomy (LC). Their study included 740 patients with cholelithiasis who underwent routine LC performed by a single surgeon using the Critical View of Safety technique. Vascular and ductal anomalies were noted and evaluated during the dissection for their impact on LC. The findings from their operations showed that 197 patients (26.62%) had vascular anomalies, while 90 patients (12.16%) had ductal anomalies. Interestingly, vascular anomalies were more common than ductal anomalies, highlighting the importance of surgeon awareness regarding their presence. In our present study, spillage occurred in 25.33 percent of the patients, while it was absent in 74.67 percent of the cases. Remarkably, the Critical View of Safety was successfully achieved in 100 percent of the patients in our study. Aberrant anatomy was encountered only in two cases, leading to their conversion to open cholecystectomy. The mean duration of the procedure in our study was 59.45 minutes.

In a study by Singh and Brunt [11], they undertook a prospective study involving 1340 patients, divided into two groups: Group-A (CVS - 700 patients) and Group-B (Infundibular technique - 640 patients). In Group-A, CVS was achieved in 98.1 percent of patients, and there were no conversions, bile leaks, or bile duct injuries (BDI). In contrast, Group-B experienced 32 conversions and 5 BDIs, including three major BDIs. The operating time for Group-A (90-110 minutes) was significantly longer than for Group-B (60-80 minutes). Their study concluded that CVS is a safe, feasible, and superior technique to the infundibular method in preventing BDI.

Furthermore, in a study by Zarin et al. [12], the CVS technique was compared to the conventional infundibular technique in 438 patients divided into groups: Group-A (LC with infundibular technique) and Group-B (LC with CVS technique). They found that the operative time was significantly reduced for LC using the CVS technique (50 minutes vs. 73 minutes). Minor leaks were comparable between the two groups, but major leaks had a significant difference. Despite the additional dissection required by the "Critical View of Safety" compared to the infundibular technique, once mastered, it proved to be a faster and safer identification technique during laparoscopic cholecystectomy.

Based on the findings presented above, the authors conclude that the Critical View of Safety (CVS) method for ductal identification is effective for laparoscopic cholecystectomy. It has successfully achieved a clear view of critical anatomical structures and reduced the risk of bile duct injury. However, additional studies and research are recommended to strengthen these findings and validate the CVS method’s effectiveness further.

This research paper received no external funding.

The authors declare no conflicts of interest.

All authors contributed equally to this paper. They have all read and approved the final version.

Informed consent was obtained from all patients participating in the study.

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