Laparoscopic cholecystectomy (LC) was first performed by Erich Mühe in 1985 (1), and it quickly became the gold standard operation for patients with symptomatic gallstones (2, 3).

Despite its clear benefits, including faster recovery and decreased postoperative pain (4), LC has been associated with increased bile duct injury (BDI) (5). Major BDI rates remain in the range of 0.3%–0.5% for LC (6) and has remained largely unchanged over time despite increasing experience with the procedure and employing better training, imaging modalities and strategic operative concepts, such as Strasberg's Critical View of Safety (CVS) (7, 8). The misinterpretation of anatomical landmarks is the primary cause of intraoperative biliary and vascular injuries (9).

The Critical View of Safety (CVS) technique was introduced in 1995 by Strasberg et al. (5) to prevent BDI. Despite universal endorsement, consistent achievement of CVS varies and may be influenced by multiple factors including patient physiology, disease severity, and surgeon characteristics (10). However, there is limited prospective data on surgeon-related factors such as experience and subspecialty.

The study aimed to prospectively assess the rate of CVS achievement and to identify patient-related, disease-related and surgeon-related factors associated with the successful achievement of CVS. Secondary outcomes were to evaluate the incidence of BDI during LC and to investigate the potential association between failure to achieve CVS and 30-day postoperative outcomes.

While prior studies have explored potential factors influencing CVS achievement, few studies have prospectively assessed the influence of patient, disease, and surgeon related factors. This study aimed to fill this gap.

Strasberg's Critical View of Safety (CVS), first introduced in 1995, is widely recognized as the safest technique for identifying the elements of the Calot triangle during laparoscopic cholecystectomy (LC) (16). It aims to standardize a “mandatory” pause during LC and to make correct identification of the anatomic structures prior to cutting or clipping to minimize the risk of bile duct injury to zero (17, 18).

Despite widespread ndorsement of the CVS technique, the scientific evidence supporting it effectiveness to prevent BDI remains controversial (16), and consistent implementation of the technique varies considerably across institutions (19). Moreover, one-fourth of surgeons who reported achievement of the CVS were found to have done so inadequately (20).

Three criteria are required to achieve the CVS (21):

The hepatocystic triangle is cleared of fat and fibrous tissue.

In this study, the overall rate of CVS achievement was 68.7%, which is higher than previously reported CVS success rates (23, 24).

Preoperative determination of difficult CVS can also help the surgeon in counseling the patients regarding higher chances for conversion to open procedure or bailout procedures. A prospective cohort study conducted in India found only neutrophil percent and lymphocyte percent to be independent risk factors for failure to achieve CVS (25).

While one might expect surgeon experience to be a dominant predictor, our findings suggest otherwise. Instead, physiological fitness had stronger associations with CVS achievement. In this study, patients with ASA grade I were significantly more likely to achieve CVS compared to ASA grade II, (p = 0.031). Which is consistent with other studies (25, 26).

Our analysis revealed that Consultants were more likely to achieve the CVS than residents (69.6% vs.60.0%) but it was not statistically significant (p = 0.55). While surgical expertise remains valuable, our findings imply that case complexity, individual patient challenges, and application of established protocols may exert a stronger influence on successful CVS achievement.

In this study, a formal time-out was performed by all residents prior to dividing the cystic duct to confirm the achievement of CVS, while consultants were less likely to perform a time-out. (n = 80, 59.3%). The SAGES 6-step program for a safe cholecystectomy (Figure 4), defines time-out as a “momentary intraoperative pause” to allow for reflection before “clipping, cutting or transecting any ductal structures” (22).

Using timeouts is a cognitive strategy for debiasing surgical decisions. It serves as a forcing function to shift from intuitive (fast) thinking to analytic (slow) thinking, particularly when applying the B-SAFE approach before any dissection to confirm spatial orientation (27) (Figure 5).

In our study, patients undergoing emergency cholecystectomies were more likely to have CVS achieved compared to elective cases (p = 0.01). 56% of patients with acute cholecystitis underwent emergent surgery (n = 28), whereas 98.8% of patients diagnosed with biliary colic had elective surgery (n = 85).

Similarly, patients with biliary colic were less likely to achieve CVS than acute cholecystitis (p = 0.031). This is contrary to other studies where acute cholecystitis and emergency surgery to be independent predictors of difficult LC (25, 26). While emergent cholecystectomies often present with distorted anatomy, the observed higher CVS achievement rate in acute cholecystitis cases may be explained by a heightened sense of caution and strict adherence to safety protocols in high risk settings. These findings should be interpreted cautiously, and future studies incorporating video documentation and external validation are warranted to explore these associations more robustly.

Notably, in our study, hepato-pancreato-biliary (HPB) surgeons, despite their high expertise, were paradoxically less likely to document CVS than other specialties, including surgical oncology, colorectal, upper gastrointestinal, and minimally invasive surgery (p < 0.001).

The paradoxical finding that non-HPB surgeons achieved CVS more frequently than HPB surgeons may reflect not only case complexity, but also variation in documentation practices, as non-HPB may follow CVS protocols more strictly or may over-document fulfillment of the three criteria to achieve the CVS—especially in protocol-driven environments like teaching hospitals. In contrast, HPB surgeons, who are often more familiar with the concept of CVS, may apply a higher threshold before declaring that the CVS has been achieved.

These findings highlight how case mix, surgical philosophy, and documentation practices can influence CVS rates. Also, they emphasize the potential role of operative culture and institutional training environments in influencing outcomes.

According to the Tokyo Guidelines 2018 for the management of acute cholecystitis, safe laparoscopic cholecystectomy is emphasized, particularly when dealing with “difficult gallbladder” cases, which may involve severe scarring or fibrosis in Calot's triangle. These guidelines recommend bailout procedures like conversion to open surgery, subtotal cholecystectomy, or the fundus-first technique to prevent bile duct-injury (28–30).

Similarly, recent “safe cholecystectomy” guidelines recommend considering bailout procedures in patients where CVS fails to be achieved (28, 31). In our study, however, all patients underwent total cholecystectomy, including those in whom the CVS could not be achieved.

Age, male gender, thickened gallbladder, pericholecystic fluid and other perioperative factors including Tokyo severity grade and Nassar difficulty grading scale were analyzed & were not statistically significant. Other studies found that age, male gender, thickened gallbladder, preoperative ERCP, to be independent predictors of difficult LC (26, 32, 33).

No significant correlation was found between CVS and 30-day postoperative complications (p = 0.431). This may suggest that while CVS is a preventive strategy against bile duct injury, its presence does not necessarily predict overall postoperative morbidity, which is influenced by a broader spectrum of perioperative factors.

The absence of bile duct injury in this study limits the ability to evaluate a potential association between achieving the Critical View of Safety and the risk of bile duct injury.

Importantly, our study reinforces that successful achievement of the CVS is not solely dependent on surgical experience, rather, it is a multifactorial outcome influenced by preoperative physiology, intraoperative strategy, and institutional culture.

Achieving the Critical View of Safety is influenced by several patient, surgical, and institutional factors. Timing of surgery (emergency, elective), indication for surgery (acute cholecystitis, biliary colic), ASA grade and surgeon subspecialty are key determinants. Surgical planning according to these factors may improve safety and standardization in laparoscopic cholecystectomy. Adherence to strict protocols is essential to ensure the consistent achievement of CVS in both elective and emergency cases. Larger multi-center studies with objective video assessments are needed to validate our findings.