The Critical View of Safety (CVS)

Laparoscopic cholecystectomy was introduced into wide practice about 1990, with demonstrated benefit to patients. However, it was associated with a sharp increase in major bile duct injuries. Biliary injuries are morbid, costly, and the source of litigation. Although not usually due to negligence, they are iatrogenic and detract from the value of laparoscopic cholecystectomy. Most major bile duct injuries are due to misidentification. In the “classical injury,” the common bile duct is thought to be the cystic duct and is divided. Aberrant hepatic ducts may also be mistakenly identified as the cystic duct or cystic artery.

The Critical View of Safety (CVS) is a method of target identification, the targets being the cystic duct and the cystic artery. Today, CVS is taught and used widely. It is accepted as a good means of identification of the cystic structures and its use is within the standard of care.

CVS is a re-working of a method of secure identification in open cholecystectomy in which the cystic duct and artery are identified, after which the gallbladder is attached only by the 2 cystic structures. The other requirement, that is, that the hepatocystic triangle be cleared of fat and fibrous tissue and that 2 and only 2 structures remain attached to the gallbladder, are the same as in the open technique.