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Defining the Critical View of Safety and Safe Steps for Parametrial Transection in Minimally Invasive Hysterectomy: A
Takayuki Takahashi1, Risa Takai2, Shin Takenaka3
1Biomedical Spatial Science Team, RIKEN Center for Advanced Intelligence Project, Nihonbashi 1-chome Mitsui Bldg., 15F, 1-4-1 Nihonbashi, Chuo-ku, Tokyo 103-0027, Japan; Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; Mathematical Intelligence for Medicine, Graduate School of Medicine, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan; Department of Artificial Intelligence and Medical Science, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan.
Objective:
To establish expert consensus on Critical View of Safety (CVS) criteria and Safe Steps for parametrial transection during minimally invasive hysterectomy (MIH) to support injury prevention and blood-loss control.
Design:
Modified Delphi consensus study.
Setting:
Nationwide online survey conducted in Japan from February through June 2025.
Participants:
Thirty-three of 34 invited expert gynecologic laparoscopic surgeons participated (response rate, 97.1%). All 33 completed all four rounds (retention rate, 100%).
Interventions:
Open-ended item generation (Round 1) was followed by iterative Likert-scale rating and wording refinement (Rounds 2-4). Consensus was defined a priori as a rate of agreement (RoA) ≥ 70%.
Results:
Consensus was reached on 20 statements across seven categories, with RoA ranging from 72.7% to 97.0%. Adopted statements included sufficient caudal bladder mobilization (RoA 97.0%), division of the cranial leaves of the vesicouterine ligaments before transection of the lateral parametrial vessels (RoA 78.8%-81.8%), confirmation of the course of the deep uterine vein before transection (RoA 97.0%), and maintaining a safe distance from the ureter when using an energy device (RoA 97.0%). The panel also endorsed adapting the steps leading up to transection according to intraoperative findings (RoA 81.8%-93.9%).
Conclusion:
This Delphi study established consensus on 20 statements for parametrial transection in MIH. These statements comprise CVS criteria, Safe Steps, and general principles and provide intraoperative checkpoints and practical guidance to support prevention of bladder and ureteral injuries, control of blood loss, surgical training, and future evaluation.
