Registering the critical view of safety: photo or video?

One of the most important ways to reduce biliary duct injury in laparoscopic cholecystectomy is to achieve the critical view of safety (CVS) before transection of the cystic artery and duct. Documenting CVS is possible with photo prints, video imaging, or both. These documentations can be used as a proof of the right procedure in case of biliary duct injury, but only if the documentation is good enough to be judged independently by others.

In 102 consecutive laparoscopic cholecystectomies, CVS was recorded by photo prints and video images. Imaging was done just before transection of the cystic artery and duct. The photo prints and video images were analyzed independently by two surgeons. These surgeons had to judge whether the documentation method was of sufficient quality to determine whether CVS was achieved.

Photo prints were made for 81% and video images for 59% of the 102 patients treated with a laparoscopic cholecystectomy. The mean age of the patients was 54 years (range, 22-83 years), and 71% were women. The diagnosis for 62 of the patients was symptomatic cholecystolithiasis, and 18 patients had acute cholecystitis. The remaining patients had earlier experienced acute cholecystitis, biliary pancreatitis, or endoscopic retrograde cholangiopancreatography (ERCP). Respectively, 30% and 21% of the CVS photo prints were judged to be of insufficient quality to determine whether CVS had been established, mostly because of difficulties adequately showing the lateral side (κ = 0.67). In all but two video images, achievement of CVS was documented sufficiently to be judged 97% (κ = 1.00).

Photo prints are inferior to video images for judging achievement of CVS. Therefore, a practical and logistical solution must be devised in hospitals for storage and insight in all video documentation, for example, by implementation of a link with the electronic patient database.